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Worms and Human Disease Second Edition R Muller
Digital Instant Download
Author(s): R Muller
ISBN(s): 9780851995168, 0851995160
Edition: Second
File Details: PDF, 4.95 MB
Year: 2002
Language: english
00Worms & H.D. - Prelims. 20/11/01 1:41 PM Page i

Worms and Human Disease

2nd Edition
00Worms & H.D. - Prelims. 14/11/01 4:24 PM Page ii

Dedicated to the memory of Annie

00Worms & H.D. - Prelims. 14/11/01 4:24 PM Page iii

Worms and Human Disease

2nd Edition

Ralph Muller, DSc, PhD, FIBiol

Department of Infectious and Tropical Diseases

London School of Hygiene and Tropical Medicine
University of London, UK

and

Former Director
International Institute of Parasitology
St Albans, Hertfordshire, UK

With contributions and the chapter on Immunology of Helminths from

Derek Wakelin, DSc, PhD, FRCPath

School of Life and Environmental Sciences

University of Nottingham, UK

CABI Publishing
00Worms & H.D. - Prelims. 14/11/01 4:24 PM Page iv

CABI Publishing is a division of CAB International

CABI Publishing CABI Publishing

CAB International 10 E 40th Street
Wallingford Suite 3203
Oxon OX10 8DE New York, NY 10016
UK USA
Tel: +44 (0)1491 832111 Tel: +1 212 481 7018
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© CAB International 2002. All rights reserved. No part of this

publication may be reproduced in any form or by any means,
electronically, mechanically, by photocopying, recording or
otherwise, without prior permission of the copyright owners.

A catalogue record for this book is available from the British

Library, London, UK.

Library of Congress Cataloging-in-Publication Data

Muller, Ralph, 1933-
Worms and human disease / Ralph Muller ; with contributions and the chapter on
immunology from Derek Wakelin.- - 2nd ed.
p. ; cm.
Rev. ed. of: Worms and disease / Ralph Muller. c1975.
Includes bibliographical references and index.
ISBN 0-85199-516-0 (pbk.)
1. Medical helminthology. 2. Helminthiasis. I. Wakelin, Derek. II. Muller, Ralph,
1933- Worms and disease. III. Title.
[DNLM: 1. Helminths- -pathogenicity. 2. Helminthiasis. QX 200 M958w 2001]
RC119.7 .M84 2001
2001025591

ISBN 0 85199 516 0

Typeset in Melior by Columns Design Ltd, Reading.

Printed and bound in the UK by Biddles Ltd, Guildford and King’s Lynn.
00Worms & H.D. - Prelims. 14/11/01 4:24 PM Page v

Contents

Acknowledgements ix

Introduction 1

1. The Trematodes 3
Morphology 5
Life Cycle Stages 6
Classification 6
Family Schistosomatidae 9
Schistosomes 9
Family Paragonimidae 32
Paragonimus westermani 32
Family Achillurbainiidae 37
Family Opisthorchidae 38
Clonorchis sinensis 38
Opisthorchis viverrini 43
Opisthorchis felineus 44
Family Dicrocoeliidae 45
Dicrocoelium dendriticum 45
Family Fasciolidae 46
Fasciola hepatica 46
Fasciolopsis buski 49
Family Heterophyidae 51
Heterophyes heterophyes 51
Metagonimus yokogawai 53
Family Paramphistomidae 55
Gastrodiscoides hominis 55
Family Echinostomidae 56
Echinostoma ilocanum 56
Other Echinostomids 56
Other Occasional and Rare Human-parasitic Trematodes 58
Family Diplostomidae 58
Family Lecithodendriidae 58
Family Plagiorchiidae 58
Family Troglotrematidae 58
Other families 59

v
00Worms & H.D. - Prelims. 14/11/01 4:24 PM Page vi

vi Contents

2. The Cestodes 63
Classification 64
Order Pseudophyllidea 65
Diphyllobothrium latum 65
Sparganosis 70
Order Cyclophyllidea 71
Family Taeniidae 71
Taenia saginata 71
Taenia solium 76
Cysticercosis 80
Taenia multiceps 83
Echinococcus granulosus 85
Echinococcus multilocularis 94
Echinococcus oligarthrus 97
Echinococcus vogeli 97
Family Hymenolepididae 98
Hymenolepis nana 98
Hymenolepis diminuta 101
Family Dipylididae 102
Dipylidium caninum 102
Very occasional human tapeworms 102

3. The Acanthocephala 106

Moniliformis moniliformis 106
Macranthorhynchus hirudinaceus 107

4. The Nematomorpha 108

5. The Nematodes 109

Classification 109
A Key to Nematodes Parasitic in Humans 113
Intestinal Nematodes 115
Geohelminths 115
Order Rhabditida 115
Family Strongyloididae 115
Strongyloides stercoralis 115
Order Strongylida 126
Family Ancylostomatidae 126
Necator americanus 126
Ancylostoma duodenale 134
Other Strongyles 137
Family Trichostrongylidae 138
Trichostrongylus spp. 138
Family Chabertiidae 139
Ternidens deminutus 139
Oesophagostomum bifurcum 140
Family Syngamidae 142
Mammomonogamus laryngeus 142
Family Angiostrongylidae 143
Parastrongylus cantonensis 143
Parastrongylus costaricensis 145
00Worms & H.D. - Prelims. 14/11/01 4:24 PM Page vii

Contents vii

Order Ascaridida 147

Family Ascarididae 147
Ascaris lumbricoides 147
Lagochilascaris minor 153
Baylisascaris procyonis 153
Family Anisakidae 154
Anisakis and other anisakids 154
Larva Migrans 156
Visceral larva migrans 156
Toxocara and Toxascaris 156
Cutaneous marva migrans or ‘creeping eruption’ 159
Order Oxyurida 160
Family Oxyuridae 160
Enterobius vermicularis 160
Order Enoplida 164
Family Trichuridae 164
Trichuris trichiura 164
Tissue Nematodes 173
Order Enoplida 173
Family Trichuridae 173
Aonchotheca philippinensis 173
Calodium hepaticum 175
Eucoleus aerophilus 175
Family Trichinellidae 176
Trichinella spiralis 176
Family Dioctophymidae 184
Dioctophyma renale 184
Superfamily Mermithoidea 184
Order Spirurida 184
Superfamily Gnathostomoidea 184
Gnathostoma spinigerum 184
Other Spirurids 187
Superfamily Filarioidea: the Filariae 188
Wuchereria bancrofti 190
Brugia malayi 202
Loa loa 206
Onchocerca volvulus 211
Mansonella perstans 221
Mansonella streptocerca 223
Mansonella ozzardi 225
Accidental filarial infections 226
Superfamily Dracunculoidea 228
Dracunculus medinensis 228

6. Other (Non-helminth) Groups 240

Pentastomes 240
Armillifer (= Porocephalus) armillata 240
Linguatula serrata 240
Leeches 241
Myiasis 241
00Worms & H.D. - Prelims. 14/11/01 4:24 PM Page viii

viii Contents

7. Immunology of Helminths 243

8. Epidemiological Aspects of Helminth Infections 252

9. Helminthological Techniques 255

Appendix 1 Summary of Some Landmarks in Medical Helminthology 271

Appendix 2 Glossary of Helminthological Terms 273
Appendix 3 Location of Helminths in the Human Body 279

General References and Further Reading 282

Index 287
00Worms & H.D. - Prelims. 14/11/01 4:24 PM Page ix

Acknowledgements

It is a pleasure to thank SmithKline McLaren (Figs 5 and 80), Prof. C.

Beecham (now GlaxoSmithKline) for a Macpherson (Plate 10), Prof. Y. Matsukado
grant that has made possible the plates of (Fig. 20), Prof. M. Murray (Plate 7), Dr
colour pictures, which have greatly Nagano (Plate 21), Prof. G.S. Nelson (Fig.
increased the usefulness of the whole book, 44), Dr M.J. Taylor (Fig. 95), Dr A.C.
and Dr John Horton of SmithKline Templeton (Fig. 40), Dr S. Townson (Plate
Beecham for his advice and also for the 31), Dr S. Vajrasthira (Fig. 18), Dr E. Watty
provision of colour photographs (Plates 24 (Plate 17), Prof. G. Webbe (Plate 3) and the
and 25). Thanks also to Dr R. Neafie for WHO (Plates 26 and 32). Thanks to Edward
providing photographs from the Armed Arnold and Professor D. Crompton for per-
Forces Institute of Pathology collection mission to reproduce Fig. 65, to CAB
(Figs 54, 62, 66, 67, 68, 75, 77 and 96 and International, and Dr P. Jordan and Dr
Plate 18), to Dr L. Savioli for photographs R. Sturrock for permission to reproduce
and a booklet from the World Health Fig. 17 and to Dr J. Baker and Harcourt for
Organization (WHO) and to Professor T. permission to publish Fig. 132.
Polderman for a photograph of My daughter Harriet kindly helped with
Oesophagostum (Plate 17). Other pho- maps and drawings and I would also like
tographs were kindly provided by Dr J. to acknowledge the help and information
Anderson (Fig. 100 and Plates 29 and 30), provided by many colleagues.
Dr Kemal Arab (Plate 23), Dr N. Ashton Professor Derek Wakelin has, in addi-
(Fig. 72), Prof. E.A. Bianco (Plate 27), Dr A. tion to writing the sections on immunology
Bryceson (Fig. 46), Dr P. Choyce (Fig. 107), for various groups of parasites as well as
Dr D. Denham (Plate 21), Prof. D. Dennis the general chapter on the subject, provided
(Plate 28), Dr F. Etges (Fig. 14), Dr R. useful criticism and advice on statements
Feachem (Plate 5), Dr D. Flavell (Plate 6), on immunology and immunodiagnosis
Dr H. Fuglsang (Fig. 106), Dr L.M. Gibbons included in the treatments of many of the
(Figs 34, 57, 61 and 85), Prof. D.B. individual parasites (possible errors in
Holliman (Figs 64 and 71 and Plates 11, 12, these parts are, of course, not his responsi-
13, and 16), Prof. S. Lucas (Plate 19), Dr D. bility).

ix
00Worms & H.D. - Prelims. 14/11/01 4:24 PM Page x
01Worms Intro. & Chap 01 14/11/01 4:24 PM Page 1

Introduction

While this book is the second edition of concerned with tropical and exotic dis-
Worms and Disease: a Manual of Medical eases and for students taking postgraduate
Helminthology (1975), because of the long degrees and diplomas in aspects of tropical
time that has elapsed since the publication and infectious diseases. It should also
of the earlier book, it has been so exten- prove useful as an accessory text and refer-
sively revised and brought up to date that ence source for undergraduate medical,
virtually every chapter has had to be zoological and tropical health engineering
almost completely rewritten. In the inter- students, and for medical technologists,
vening years the importance to humans of microbiologists and physicians in temper-
some new helminths has emerged, such as ate climates. With increase in air travel,
Oesophagostomum bifurcum and Para- most hospitals and medical practitioners in
strongylus costaricensis, but principally developed countries are meeting cases of
the changes have been necessitated by the parasitic infections that may have been
great strides that have been made in knowl- very rare occurrences in the past, and it is
edge of the diagnosis, treatment, immunol- becoming increasingly necessary to ask of
ogy and molecular biology of parasites. The almost all patients ‘Unde venis?’. Also, if
chapter on the immunology of helminths global warming increases, it is likely that
(now written by Derek Wakelin) has been the endemicity of some helminth infec-
greatly amplified, with the addition of tions will extend to higher latitudes.
more detailed paragraphs in the appropri- The format of this book is fairly conven-
ate sections, together with the latest infor- tional, with parasites considered in order
mation on the prospects for specific of their zoological relationships rather than
vaccines. There has also been exciting their location in the body. The latter
progress in the field of global control of approach may be useful for diagnosis but is
various helminths, such as the schisto- not practical for other aspects of the sub-
somes, soil-transmitted nematodes, filariae ject, as some parasites can occupy a wide
(both those causing lymphatic filariasis and range of sites in the body, so that there
those causing onchocerciasis) and the would be a great deal of repetition, and
guinea worm. Most of these campaigns also because the relationships between
have been possible because of recent many similar parasites that occupy differ-
advances in chemotherapy and, in some ent organs would be obscured. However,
cases, of diagnosis; many have been linked the various possible locations in the body
with efforts to improve sanitation and of all the important helminths are shown
general health. in Fig. 132 and alternative diagnoses are
The book is intended principally as a discussed in the appropriate individual
practical guide in human helminthology sections. An attempt has also been made to
for physicians and medical technologists have the best of both worlds, e.g. all the

1
01Worms Intro. & Chap 01 14/11/01 4:24 PM Page 2

2 Introduction

intestinal nematodes are considered in the reported, however occasionally (a total of

same section so that the new global mea- 267 species), and includes a brief consider-
sures being advocated for all the geo- ation of other metazoan parasites some-
helminths can be considered together, even times found in humans, such as the
though they are not all closely related. pentastomids, dipteran fly larvae and
Most of the figures for infection rates leeches, which may be confused with the
have been obtained from the CD-ROM true helminths.
PARASITE database produced by CAB While the title is Worms and Human
International or from MEDLINE. Maps Disease, it must not be assumed that
have concentrated principally on helminth helminth infection invariably results in
infections that have a focal distribution. disease; most of the helminths that are pre-
The term helminth (Greek µ) means dominantly human parasites are patho-
worm, although it is usually restricted to genic only when worm burdens are high
the parasitic worms. The term does not and, as there is no multiplication within
refer to any one zoological taxon but those the body, light infections become clinically
members parasitic in humans belong important only following reinfection. The
almost entirely to two main groups; the majority of helminth infections are light
phylum Platyhelminthes, which includes and cause little morbidity (although in
the trematodes (flukes) and the cestodes some cases more than was previously
(tapeworms), and the phylum Nematoda, thought), but many are so widespread that
comprising the nematodes (roundworms). the low percentage of patients who suffer
This book provides a comprehensive severe clinical disease represents a prob-
account of all important helminths found lem of great medical and economic
in humans, with a mention of all others importance.
 1
The Trematodes

Adult trematodes, or flukes, may be found means synonymous with the presence of
in the intestinal tract, bile-ducts, lungs or disease. In contrast to viruses, bacteria or
blood of humans. Some details concerning protozoans, trematodes do not multiply
the medically most important species are within the human body and the few organ-
shown in Table 1. All the trematodes men- isms present in the great majority of
tioned in the table are normal human para- infected persons are tolerated with the
sites, except some species of Paragonimus minimum of inconvenience and are often
and Fasciola and some heterophyids and not diagnosed. It is the small percentage of
echinostomes, which are accidental para- patients with large worm burdens (so-
sites with humans not being involved in called ‘wormy people’) or in whom the par-
their transmission cycles. However, almost asites or their eggs are in ectopic sites in
all trematodes are very catholic in their the body who give cause for alarm.
choice of definitive hosts (a notable excep- The digenetic trematodes are members
tion is Schistosoma haematobium) and of the phylum Platyhelminthes, which also
have a wide range of animal reservoirs; 144 includes the cestodes (tapeworms), mono-
species that have been found in humans geneans (ectoparasites of fishes and
are mentioned in the text, most of which amphibians) and free-living turbellarians
are natural animal parasites. Not shown in (planarians, etc.). Platyhelminthes, or flat-
the table are various aberrant forms, such worms, are acoelomate bilateria (bilaterally
as the cercarial larvae of animal and bird symmetrical and lacking a coelom). The
schistosomes, which can penetrate the skin excretory system is based on the flame cell,
of humans but are not able to mature. or protonephridium, and often the pattern
Pre-eminent in medical and economic of flame cells can be of importance in clas-
importance are the schistosomes, or blood sification. Trematodes are characteristically
flukes, which are the cause of one of the flat and leaflike, or occasionally globular,
major human diseases, schistosomiasis. hermaphroditic organisms (except for the
This is a source of suffering in many warm schistosomes, which have a male folded
countries and is a major cause of morbid- about its long axis and a cylindrical female
ity. No other trematode is the cause of such (Figs 3 and 4)). All have complicated life
widespread morbidity, but liver flukes cycles with alternating sexual and asexual
(Clonorchis and the closely related development in different hosts. Asexual
Opisthorchis) and lung flukes (Paragonimus) multiplication takes place in a snail, and
are important parasites in areas of Asia and for parasites of medical importance this is
their presence may result in severe disease always a gastropod snail. It is believed that
and possibly death. the trematodes were originally parasites of
It needs to be stressed that the presence molluscs and they are still always very
of trematode parasites in the body is by no specific in their choice of snail host;

3
 4
Table 1. Trematodes of medical importance.

Chapter 1
Situation of Eggs recovered Snail intermediate Other intermediate Geographical
Habitat Species adult from host or transport hosts distribution
Blood Schistosoma Mesenteric veins Faeces Biomphalaria spp. None (active penetration Africa, South America
mansoni by cercariae)
S. japonicum Mesenteric veins Faeces Oncomelania spp. None (active penetration China, South-East Asia
by cercariae)
S. mekongi Mesenteric veins Faeces Neotricula None (active penetration Cambodia, Laos
by cercariae)
S. intercalatum Mesenteric veins Faeces Bulinus spp. None (active penetration Central Africa
by cercariae)
S. haematobium Vesicular veins Urine Bulinus spp. None (active penetration Africa, Middle East
by cercariae)
Lungs Paragonimus Cysts in lungs Sputum and faeces Semisulcospirura Edible crustaceans South-East Asia,
westermani Thiara containing China, Japan
Oncomelania metacercariae
Paragonimus spp. Cysts in lungs Sputum and faeces Various Edible crustaceans South-East Asia,
containing West Africa, South and
metacercariae Central America
Liver Clonorchis sinensis Bile and pancreatic Faeces Bulimus Freshwater food fish South-East Asia
ducts Parafossarulus containing metacercariae
Opisthorchis felineus Bile and pancreatic Faeces Bithynia Freshwater food fish Siberia, East Europe
ducts containing metacercariae
O. viverrini Bile and pancreatic Faeces Bithynia Freshwater food fish Thailand, Laos
ducts containing metacercariae
Fasciola hepatica Bile ducts Faeces Lymnaea Metacercariae encysted Cosmopolitan (mainly
on plants temperate areas)
Intestine Fasciolopsis buski Small intestine Faeces Segmentina Metacercariae on South-East Asia, India
water plants
Heterophyes Small intestine Faeces Pirenella Freshwater food fish South-East Asia,
heterophyes Cerithidea containing metacercariae Middle East, Egypt,
southern Europe
Metagonimus Small intestine Faeces Semisulcospira Freshwater food fish South-East Asia, Russia
yokogawai containing metacercariae (Siberia), southern Europe
Other heterophyids Small intestine Faeces Various Freshwater food fish Worldwide in warm
containing metacercariae countries
Echinostomes Small intestine Faeces Various Freshwater fish or snails Mostly South-East
containing metacercariae Asia, India
Gastrodiscoides Caecum and colon Faeces Helicorbis Metacercariae on South-East Asia
hominis water plants
 The Trematodes 5

identification and study of the biology of Morphology

the particular snails involved in transmis-
sion form an important aspect of the epi- The outer surface or tegument is a non-
demiology of trematode diseases, known as cellular syncytial extension of the
medical malacology. sunken tegumental cells, and may have
Detailed consideration of snail inter- spines embedded in it. During the last
mediate hosts is outside the scope of this few years a great deal of interest has
book. For the practical field worker it is nec- been shown in the physiology and fine
essary to consult a specialized monograph structure of the tegument of both trema-
(e.g. Malek, 1963; Brown, 1980) or send todes and cestodes, because of its impor-
specimens to an expert, as in most habitats tance in nutrition and in antigenic
there are species of snails present which do stimulation (it is considered in more
not transmit human helminth infections but detail on p. 63 in the section on
closely resemble those that do. Some of the cestodes).
important snail intermediate hosts involved Two suckers are present in all trema-
in the dissemination of trematodes of med- todes found in humans, an anterior oral
ical importance are shown in Fig. 1. sucker into which the alimentary canal

Fig. 1. Snails that act as first intermediate hosts of the trematodes of medical importance.
(a) Biomphalaria glabrata from Brazil, host of Schistosoma mansoni. (b) Bulinus (Physopsis) globosus
from Nigeria and (c) Bulinus (Bulinus) truncatus from Iran, hosts of S. haematobium. (d) Oncomelania
hupensis nosophora from Japan, host of S. japonicum. (e) Thiara granifera from China and
(f) Semisulcospira libertina from China, hosts of Paragonimus westermani and Metagonimus yokogawai.
(g) Polypylis hemisphaerula from China, host of Fasciolopsis buski. (h) Parafossarulus manchouricus
from China, host of Clonorchis sinensis. (i) Codiella (= Bithynia) leachi from Germany, host of
Opisthorchis felineus. (j) Pirenella conica (from Egypt) host of Heterophyes heterophyes. (k) Lymnaea
trunculatula from England, host of Fasciola hepatica.
6 Chapter 1

opens and a more posterior ventral Life Cycle Stages

sucker, or acetabulum, by which the
worm attaches itself to its host. In Adults are hermaphrodite, except for the
Heterophyes there is also an accessory schistosomes, which have separate sexes –
genital sucker. the egg reaches water (in the schistosomes,
The features of importance in the opisthorchiids and heterophyids the egg
recognition and classification of a trema- contains a larva, termed a miracidium,
tode are shown in Fig. 2 and the morphol- when passed out; in other trematodes the
ogy of the flukes of medical importance larva develops inside the egg over a few
in Fig. 3. weeks) – the ciliated miracidium larva
hatches from the egg and penetrates a spe-
cific freshwater snail (except in
opisthorchiids, where the egg containing a
larva is ingested by the snail) – inside the
snail the miracidium develops into an
irregular sac-like sporocyst – germ cells
inside this primary sporocyst form the next
larval stage (these are termed rediae in
most trematodes, where they have a rudi-
mentary gut, but secondary sporocysts in
schistosomes, where they are similar to the
primary sporocysts), which burst out and
invade new tissues of the snail (principally
the digestive gland) – germ cells inside
these in turn develop into the next larval
stages, the tailed cercariae, which escape
from the snail into the water (in some
forms there are two redial generations).
Thus one miracidium can give rise to many
thousands of cercariae, the process taking
several weeks or even months. The cer-
cariae actively penetrate through the skin,
as in the schistosomes, or form cysts
(metacercariae) in a second intermediate
host or on vegetation and are passively
ingested in all other trematodes.

Classification

The classification given below is based prin-

cipally on that of La Rue (1957), in which
the life history and the larval stages are con-
sidered as well as the morphology of the
adult; more conservative classifications were
based entirely on the adult. The divisions at
the family level are generally accepted by
most authorities, but those taxa above this
level are still controversial (Gibson and Bray,
Fig. 2. Diagram of Clonorchis sinensis to show 1994). Recent studies utilizing computer-
the features of taxonomic importance in the based cladistic analysis and molecular biol-
digenetic trematodes. ogy might alter the familiar groupings in the
 The Trematodes 7

future (Brooks et al., 1985; Rohde et al., The modes of infection of trematodes
1993), but changes are not generally of medical importance shown in Table 2
accepted. Only a very few of the numerous reflect quite well the taxonomic divisions
families comprising the subclass Digenea are (the odd one out being Echinostoma, in
included (Yamaguti, 1971) – those which which it might be expected that the
have members of medical importance. cercariae would encyst on vegetation).

Fig. 3. Diagrams of the shape and principal organ systems of the hermaphrodite trematodes of medical
importance (schistosomes are shown in Fig. 4). Comparative sizes shown in silhouette.
8 Chapter 1

Table 2. Mode of infection of trematodes of medical importance.

Cercaria liberated from snail

Active penetration Encystment to give

of skin of definitive host metacercaria, which is
ingested by definitive host

Schistosoma

Encystment on vegetation 2nd intermediate host required

ˇ

Fasciolopsis
Fasciola
Gastrodiscoides?

Fish Crustacean Snail Insect

Clonorchis Paragonimus Echinostoma Dicrocoelium

Opisthorchis Plagiorchis
Heterophyes
Metagonimus

KEY: Members of the group occur in Dioecious

M = mammals, B = birds, R = reptiles, Schistosoma
A = amphibians, F = fish.
SUPERFAMILY DIPLOSTOMOIDEA
Family Diplostomidae (MB)
PHYLUM PLATYHELMINTHES
Body usually divided into two regions.
CLASS TREMATODA Metacercariae in fishes or amphibians.
Alaria, Neodiplostomum
SUBCLASS DIGENEA
Endoparasites with an indirect life cycle SUPERFAMILY GYMNOPHALLIOIDEA

utilizing a snail as an intermediate host. Family Gymnophallidae (MB)

Uterus has numerous coils containing Large oral sucker, small ventral sucker.
many eggs. Single excretory pore at post- Tegument with spines.
erior end of the body. Gymnophalloides

SUPERORDER ANEPITHELOICYSTIDA Order Echinostomomida

The cercaria has a thin-walled, non-epithelial Eggs operculate. Cercariae encyst on
bladder. herbage or in other molluscs.
SUPERFAMILY ECHINOSTOMATOIDEA
Order Strigeida
Cercaria fork-tailed. Testes in tandem behind ovary.
Family Echinostomatidae (MBRF)
SUPERFAMILY SCHISTOSOMATOIDEA Head collar with row of spines.
Family Schistosomatidae (MB) Echinostoma
 The Trematodes 9

Family Fasciolidae (M) Family Paragonimidae (MB)

Suckers close to each other. Large, spiny, Many are parasites of the lungs. Vitellaria
lanceolate flukes, usually found in herbivores. compact and dense. Cuticle spinous. Testes
Fasciolopsis, Fasciola adjacent behind ovary. Cercariae encyst in
crustaceans.
SUPERFAMILY PARAMPHISTOMATOIDEA (MB)
Paragonimus
Sucker at anterior and posterior extremities
of body but no oral sucker.
Family Paramphistomatidae (or Zygo- Family Plagiorchiidae (MBRAF)
cotylidae) Cuticle spinous. Suckers well apart. Testes
Body thick and fleshy. Testes in tandem in in tandem behind ovary. Metacercariae in
front of ovary. Metacercariae on vegetation insects.
or on snail. Plagiorchis
Gastrodiscoides, Watsonius
Family Troglotrematidae (M)
SUPERORDER EPITHELIOCYSTIDA Cercariae encyst in fish or crustaceans.
Cercaria has an additional thick-walled
Genital pore posterior to ventral sucker.
epithelial bladder.
Spinous body.
Order Plagiorchiida Nanophyetus
Eggs operculate.

SUPERFAMILY DICROCOELIOIDEA
Cercariae encyst in arthropods and have an
oral stylet. Family Schistosomatidae
Family Dicrocoeliidae (MBRA)
Found in intestine, liver, gall-bladder and Schistosomes
pancreas. The oral sucker is subterminal.
Testes adjacent or in tandem, anterior to At least seven species are parasites of
ovary. Vitellaria posterior to ventral humans: Schistosoma haematobium
sucker. (Bilharz, 1852); Weinland, 1858; S. mansoni
Dicrocoelium Sambon, 1907; S. japonicum Katsurada,
1904; S. intercalatum Fischer, 1934; S.
SUPERFAMILY OPISTHORCHIOIDEA (MBR) malayensis Greer, Ow-Yang and Yong,
Cercariae encyst in or on fish. 1988; S. mekongi Voge, Bruckner and
Family Opisthorchiidae (MB) Bruce, 1978; S. sinensium Pao, 1959.
Suckers weak. Semi-transparent flukes
found in bile-ducts and gall-bladder. Testes
in tandem behind ovary.
SYNONYMS (for S. haematobium)
Clonorchis, Opisthorchis, Metorchis
Distoma haematobia Bilharz, 1852;
Family Heterophyidae (MB) Bilharzia haematobium Diesing, 1859.
This is a large family. All members are
potential parasites of humans. They are
minute flukes with a spinose tegument. LOCAL NAMES
Testes adjacent behind ovary. Au chung (Chinese), Tsagiya (Hausa, S.
Heterophyes, Metagonimus haematobium), Katayamabayo, Suisho-
SUPERFAMILY PLAGIORCHIOIDEA choman or Harapari (Japanese), Laremo
Family Lecinthodendriidae (MBRA) (Luo, S. haematobium haematuria), Kadi
Small spiny flukes with gonads in fore- dhig (Somali, S. haematobium haema-
body. Oral sucker large, ventral sucker turia), Kichocho (Swahili), Pa-yard bai-
small. Metacercariae in aquatic insects. mai lohit (Thai), Atosi eleje (Yoruba, S.
Phaneropsolus, Prosthodendrium haematobium).
10 Chapter 1

DISEASE AND POPULAR NAMES S. japonicum. China, Indonesia,

Schistosomiasis or schistosomosis*, uri- Philippines, Thailand (an S. japonicum-
nary schistosomiasis (S. haematobium), like parasite which is probably distinct).
intestinal schistosomiasis (S. mansoni, S.
japonicum, S. intercalatum and S. S. malayensis. Malaysia.
mekongi), schistosomiasis haematobium,
intercalatum, japonicum, mansoni or S. mekongi. Cambodia, Laos.
mekongi; Katayama disease (early phase of
S. japonicum); bilharziasis; bilharzia. S. sinensium. China, Thailand.
GEOGRAPHICAL DISTRIBUTION
MORPHOLOGY
It has been estimated that about 220
Unlike all the other trematodes of medical
million people are infected in the world
importance, the sexes are separate (dioe-
in 74 countries, with 600 million at risk;
of those infected 20 million have severe cious). In all species the male worm is
disease, 120 million have mild symptoms characteristically boat-shaped, with a cen-
and 80 million are symptomless (WHO, tral canal (gynaecophoric canal) in which
1993). the female lives. The cuticle of the male is
smooth in S. japonicum (the adults of S.
S. haematobium. Africa: most of the coun- malayensis and S. mekongi are identical)
tries of North Africa; widespread in Central but has tuberculations in the other three
and West Africa; in eastern Africa present important species. There are two small
from Somalia to the Cape and on the suckers and a varying number of testes in
islands offshore, including Madagascar and the different species. The female is longer
Mauritius. Middle East: present in most than the male but much thinner and circu-
countries. There might also be small foci in lar in cross-section. The two suckers of the
India around Bombay and in Madras State. female are very small and weak. The char-
A total of about 90 million people are acteristics of the various species are given
infected worldwide. in Table 3 and Fig. 4.

S. mansoni. Africa: North Africa (Morocco, S. haematobium. The male measures

Tunisia, Egypt, southern Sudan); East 10–20 mm
0.9 mm and the cuticle has
Africa (from Ethiopia down to South Africa fine tuberculations. There are 4–5 testes.
and Madagascar); most countries of Central The female has a long uterus, with the
and West Africa; Middle East (Lebanon, ovary in the posterior third of the body.
Oman, Saudi Arabia, Somalia, Yemen); There are 10–100 eggs in the uterus at one
Americas: in South America and some of time.
the Caribbean islands.
S. mansoni (Fig. 5). The adults are smaller
S. intercalatum. There are limited foci in than those of the other species. The male
Central Africa including Cameroon, Congo, measures 6–13 mm
0.75–1.0 mm and the
Congo Democratic Republic (Zaire), cuticle has coarse tuberculations. There are
Equatorial Guinea, Gabon, São Tomé and 4–13 (usually 6–9) testes. The ovary of the
Principe, and possibly in Central African female is situated anteriorly. There is usu-
Republic, Chad, Mali and Nigeria. ally only 1 egg in the uterus at one time.

*This is the standardized nomenclature for parasitic diseases advocated by the World Association for
the Advancement of Veterinary Parasitology (WAAVP) (Kassai et al., 1988. Veterinary Parasitology 29,
299–326) and the World Federation of Parasitologists (WFP), but has not been widely adopted in
medical helminthology, particularly by the World Health Organization (WHO). For instance, of the titles
of references in this book, 112 have -iasis endings and 16 -osis, most of which are mentioning
cysticercosis or echinococcosis – used in both systems.
 The Trematodes 11

Map 1. Distribution of Schistosoma haematobium, S. japonicum and S. mekongi.

S. japonicum (S. malayensis and S. ium. Eggs of each species can be recognized
mekongi). The male measures 12–20 mm
by differences in size and morphology
0.5–0.55 mm and has no cuticular tubercu- (Table 3 and Fig. 6). On immersion in fresh
lations. There are 6–7 testes. The female water, particularly under conditions of
has the ovary at about the middle of the warmth and light, they hatch almost imme-
body. There are 5–200 eggs in the uterus at diately. The miracidium larvae (Fig. 7)
one time. swim actively by means of the cilia with
which they are covered and attempt to pen-
S. intercalatum. The male measures etrate any freshwater snail they come into
11–14 mm
0.3–0.4 mm. There are 2–7 contact with. The miracidia die in 16–32 h
testes. The female has 5–60 eggs in the if they do not succeed in reaching a suitable
uterus at one time. snail intermediate host. Like all trematodes
Of the complete 270 Mb genome of they are extremely host-specific in regard to
Schistosoma, 18–24% has so far been the snails in which they will develop, often
deposited in a database (Williams and far more so than in the definitive host. The
Johnston, 1999). species of snail parasitized depends on the
geographical region, but S. haematobium
LIFE CYCLE and S. intercalatum develop in snails of the
The eggs are passed in urine in S. haemato- genus Bulinus, S. mansoni in Biomphalaria
bium and in the faeces in all the other and S. japonicum in Oncomelania.
species and contain a fully formed miracid- Oncomelania differs from the other two
12 Chapter 1

Map 2. Distribution of Schistosoma mansoni and S. intercalatum.

genera of snails in that it is amphibious, weeks and those of S. japonicum after 7

rather than aquatic, and dioecious (with weeks. The principal stimulus for emer-
separate sexes) and has an operculum on gence is light and different species emerge
the bottom surface of the foot (to prevent at various times in the day. The cercariae
drying up). Once in a susceptible snail, the measure 300–400 µm
50–70 µm and
miracidium loses its outer ciliated epider- have forked tails (furcocercus type) (Fig. 8).
mal layer and develops into a mother They swim around in the water, usually tail
sporocyst. This becomes filled with germ first, and often hang from the surface film.
balls, which burst out after about 8 days, They are infective for only a day or so in
and most of these migrate to the digestive water. Not all the cercariae mature at the
gland, where each develops into a thin- same time and usually a proportion
walled daughter sporocyst. A further continue to emerge throughout the life of
process of asexual multiplication takes the snail, which may be many months.
place and each daughter sporocyst becomes When humans enter the water the cercariae
filled with the final larval stages, the penetrate the skin, often between the hair
cercariae. Thus one miracidium can give follicles, by means of the anterior spines
rise to thousands of cercariae, all of the and the cytolytic secretions of the cephalic
same sex. At about 26°C, the cercariae of S. glands. The tail is shed in the penetration
intercalatum begin to emerge 3 weeks after process, which takes 3–5 min, and the
infection, those of S. mansoni after 4–5 immature schistosomes (known as schisto-
weeks, those of S. haematobium after 5–6 somula) enter peripheral lymphatics or
Table 3. Differential features of schistosomes of humans.
Schistosoma Schistosoma Schistosoma Schistosoma Schistosoma
japonicum mansoni haematobium intercalatum mekongi

Situation in human Mesenteric veins Mesenteric veins Vesical veins Mesenteric veins Mesenteric veins
Male
Length (mm) 10–20 6–12 10–14 11–14 15
Width (mm) 0.5 1.1 0.9 0.3–0.4 0.4
No. of testes 6–7 4–13 (usually 6–9) 4–5 2–7 (usually 4–5) 6–9
Tuberculations None Coarse Fine Fine None
Caecal junction Posterior third of body Anterior third of body Middle Middle Posterior third of body
Female
Length (mm) 20–30 10–20 16–20 10–14 12
Width (mm) 0.3 0.16 0.25 0.15–0.18 0.23
Uterus Anterior half of body Anterior half of body Anterior two-thirds of body Anterior two-thirds of body Anterior half of body
Number of eggs in
uterus 50–200 1–2 10–50 5–60 10+
Position of ovary Middle Anterior third of body Posterior third of body Posterior half of body Posterior half of body
Mature egg shape Round with small knob Lateral spined Terminal spined Terminal spined Round, small knob
and mean size 85 µm
60 µm 140 µm
61 µm 150 µm
62 µm 176 µm
61 µm 57 µm
66 µm
Mode of voiding eggs Faeces Faeces Urine Faeces Faeces
Egg production per 3500 100–300 20–300 150–400 ?
female per day (in
experimental animals)
Reaction of egg to Positive Positive Negative Positive Positive?
Ziehl–Neelsen stain
Intermediate Oncomelania Biomphalaria Bulinus Bulinus Tricula
host snail






























The Trematodes
Distribution overlap None Over most of Africa Throughout range None

13
14 Chapter 1

Fig. 4. Diagram of the structures of the three major schistosome species. Only the male of
S. mansoni is shown. The males of the other species differ principally in the number of testes, while
that of S. japonicum has a smooth tegument.

Fig. 5. Integument and double outer membrane of S. mansoni. Electron micrograph. Original
magnification
83,500.

venous vessels and are carried to the lungs pairs. The schistosomula are usually
4–7 days after penetration (Figs 9 and 10). assumed to travel to the liver via the blood
The schistosomula move from the lungs to system (against the blood flow) but, at least
the portal vessels and there grow into adult for those of S. japonicum, some penetrate
schistosomes, which mate and remain in directly through the diaphragm. The adult
Fig. 6. Eggs of (a) S. haematobium, (b) S. mansoni and (c) S. japonicum. Actual size of (a) is 125 µm.

The Trematodes
15
16 Chapter 1

Fig. 7. Ciliated miracidium of S. mansoni. Note anterior penetration glands. Dark field. Actual size 80 m.

worm pairs migrate to the mesenteric veins

(S. intercalatum, S. japonicum, S. mansoni
and S. mekongi) or the veins of the vesical
plexus surrounding the bladder, migrating
through the anastomoses between the
portal and systemic veins in the pelvis (S.
haematobium).
Eggs of S. japonicum and S. mansoni first
appear in the stools 25–28 days after cercar-
ial penetration, those of S. intercalatum
after 50–60 days and those of S. haemato-
bium in the urine after 54–84 days. Adult
worms of each species can live for as long as
25 years in people who have moved from a
non-endemic area, but it is probable that
longevity is usually considerably less in
endemic areas (3–10 years) and in children
is about 2–5 years. Large numbers of worms
may be present, up to 400 having been
found at autopsy, but in most cases there are
fewer than ten worm pairs present. Each
female of S. japonicum produces about 3500
eggs per 24 h, of S. mansoni 100–300, of S.
haematobium 20–30 and of S. intercalatum
150–400. The number of eggs produced by
S. haematobium decreases with age (Agnew
et al., 1996).
It has been reported that S. japonicum
can undergo vertical transmission (cf.
Alaria; p. 59), but this appears to be coin-
Fig. 8. Diagram of the cercaria of S. japonicum. cidental (Shoop, 1994).
 The Trematodes 17

HUMAN
ADULTS mature
in 6–12 weeks.
In veins of bowel:
S.m., S.j., S.i.
In veins of bladder:
S.h.

liver
Some EGGS retained
lungs in tissues
lymph and veins
to heart

SCHISTOSOMULA
in skin
EGGS
Male and female In urine: S. haematobium
CERCARIAE In faeces: all others
penetrate skin

MIRACIDIA (0.1 mm)

hatch immediately
in water and can
live for 24 h.
CERCARIAE (0.4 mm) Penetrate suitable
infective for 8 snail
hours in water.
Penetrate skin

SNAIL S.m.
CERCARIAE emerge
Asexual Biomphalaria spp. .
reproductive S .j
SECONDARY
SPOROCYSTS stages in
i.
S.

in digestive snail 4–7

d

gland weeks
an
h.
S.

PRIMARY Oncomelania spp.

SPOROCYSTS

MIRACIDIA
penetrate snail

Bulinus spp.

Fig. 9. The life cycle of schistosomes. Figure from Book of the Dead papyrus. S.m., S. mansoni; S.j.,
S. japonicum; S.h., S. haematobium; S.i., S. intercalatum.

CLINICAL MANIFESTATIONS AND PATHOGENESIS bladder, while with S. japonicum, S. man-

The clinical manifestations and pathogene- soni, S. mekongi and, to a lesser extent, S.
sis of S. haematobium infection differ from intercalatum, the granulomas surrounding
those caused by the other species and will the eggs cause colitis, and eggs reaching
therefore be considered separately. Briefly, the liver cause presinusoidal block to the
this is because with S. haematobium the hepatic portal flow, leading to portal hyper-
eggs accumulate progressively in the blad- tension. However, with all species, the
der and ureters and the reaction to them pathology depends on the target organs,
leads to cystitis, hydronephrosis, ureteric intensity and duration of infection, host
obstruction and occasionally cancer of the human leucocyte antigen (HLA) type and
18 Chapter 1

Fig. 10. Diagram of a 12-day-old schistosomulum

of S. mansoni recovered from the lungs.

race, host immunological responses and

concomitant infections such as hepatitis.

S. haematobium

Invasive stage. A cercarial dermatitis

(‘swimmer’s itch’) may appear 24 h after
first infection but seldom lasts more than Fig. 11. Inner surface of the bladder showing
nests of calcified ova (‘sandy patches’) (arrowed)
48 h. It is rarely met with in people
of S. haematobium.
indigenous to an endemic region and is
more common after penetration by cer-
cariae of non-human species of schisto- micturition are typical clinical signs and
somes. may persist intermittently for years. Cystitis
is caused by hyperplasia of the epithelium
Acute phase. There are usually no symp- (which occasionally becomes 2–3 cm thick),
toms until 5–10 weeks after infection, sometimes with papilloma formation, and a
when there may be mild allergic manifesta- markedly reduced bladder capacity often
tions in visitors but these are rare in results. This, together with the ureteritis,
indigenous populations. can lead to hydroureter, hydronephrosis
(Fig. 12) and uraemia. Hydronephrosis is
Chronic phase. Maximum egg production not necessarily only a late sequel of infec-
begins 10–12 weeks after infection. In tion, as it has been observed in over 8% of
schistosomiasis it is the egg that is the preadolescent children in both East and
important pathogenic agent. The majority West Africa. It may be reversible after anti-
of eggs pass through the bladder but an schistosomal treatment (Subramanian et al.,
unknown proportion are trapped in the 1999) and is probably caused by oedema,
bladder wall and ureters and eventually congestion, inflammation and possibly pro-
die and calcify. The earliest bladder lesion liferative lesions (although granulomas of
is the pseudotubercle, but in long-standing the kidneys are very rare).
infections nests of calcified ova (‘sandy Fibrosis of the ureteral wall usually leads
patches’) (Fig. 11) are surrounded by to dilatation, while strictures occur in less
fibrous tissue in the submucosa and make than 1% of patients. Cancer of the bladder is
the bladder wall visible on X-ray or by particularly common in Egypt and
ultrasonography (Hatz, 2000). Mozambique and is clearly predisposed to
Haematuria (found in about 50% of by urinary schistosomiasis (IARC Working
cases), dysuria and increased frequency of Group, 1994) but some other precipitating
 The Trematodes 19

Fig. 12. Intravenous pyelogram of a woman infected with S. haematobium showing bilateral hydronephrosis
with deformity of both ureters.

factors, such as the presence of nitrosamines parts of the genital tract, including the
in the urine, are probably involved (Mostafa cervix, vagina and vulva, and about 6–27%
et al., 1995). Squamous carcinoma is more of such cases result in sterility.
common than transitional carcinoma (Fig.
13). It has been estimated that schistosomia-
S. japonicum, S. mekongi, S. mansoni
sis is responsible for about 16% of cases of
and S. intercalatum
bladder cancer in Egypt. In the Nile Delta
region, men do most of the agricultural
work and thus become infected, resulting in Invasive phase. As for S. haematobium.
a 12:1 male-to-female bladder cancer ratio.
Pulmonary arteritis progressing to irrevers- Acute phase. Allergic manifestations, such
ible and lethal cor pulmonale because of as pyrexia, headache, oedema, cough,
capillary damage by eggs sometimes occurs dysenteric symptoms, pruritus and
when eggs are swept back into the lungs. urticaria, occur 3–8 weeks after infection
The presence of adult worms in the lungs with S. japonicum. This is known as the
following drug treatment is also a possible Katayama syndrome and may be accompa-
cause of pulmonary damage. In women, nied by tenderness in the liver region, mild
eggs may cause lesions in the ovaries, abdominal pain, lymphadenopathy and
Fallopian tubes and uterus or in the lower splenomegaly, with an accompanying
20 Chapter 1

Fig. 13. Section of bladder. Eggs of S. haematobium (many are calcified or ‘black’ eggs) can be seen
with epithelial squamous cell metaplasia (arrowed).

eosinophilia. This is possibly caused by a associated with chronic lesions of S. japon-

form of ‘serum sickness’ (acute immune icum in a small proportion of cases (IARC
complex disease) resulting from an excess Working Group, 1994). The increasing fibro-
of antigen when eggs are first produced. sis of the colon wall means that eggs are
The acute phase of S. mansoni and S. inter- repeatedly carried to the liver in the portal
calatum infection is rarely recognized in veins and become lodged in the portal
an indigenous population. tracts or, less frequently, in the lobules or
sinusoids. The eggs become the centre of a
Chronic phase. In the majority of individu- pseudotubercle, in which they are engulfed
als, infection is light and symptoms are by multinucleate giant cells and sur-
entirely absent, but in heavy infections rounded by inflammatory cells (eosinophils,
about 50% of the eggs are trapped in the macrophages and polymorphonuclear
mucosa and submucosa of the colon, result- leucocytes). In the early stages there is a
ing in the formation of pseudotubercles, microabscess surrounding each egg, resem-
which coalesce and form larger granuloma- bling miliary tuberculosis (Fig. 14).
tous reactions and pseudopapillomas. Eggs However, the cell types differ from a typical
of S. japonicum, in particular, are inclined tubercle. As the lesion heals, some degree
to die and eventually to calcify in the colon of fibrosis is usually left. Finally the
and many thousands of calcified eggs may miracidium in the egg dies and the
be found in the thickened mucosa (Plate 1). mononuclear cells form Langhans-type giant
Intestinal damage, however, is usually cells. Experiments in mice have demon-
accompanied by few symptoms except a strated that CD4+ T lymphocytes are neces-
vague feeling of ill health, with perhaps sary for the formation of granulomas. While
headache, abdominal pain and diarrhoea. the formation of granulomas is usually
Papillomas and inflammatory polyps often taken to be a host response to sequester the
develop, and in severe cases, can lead to eggs, it is possible that mobile granulomas
obstruction of the lumen of the colon. The can aid in ‘transporting’ the eggs across tis-
ulceration of the colon caused by the eggs sues to reach the faeces or urine (Doenhoff
of S. mansoni can result in a blood loss of et al., 1986; Damian, 1987). Pigment, chemi-
up to 12.5 ml day1 by patients in Egypt, cally but not structurally indistinguishable
where papillomas are particularly common. from malarial pigment, becomes deposited
Carcinomas of the large intestine are also in the Kupffer cells, portal tracts and
 The Trematodes 21

Fig. 14. Egg granuloma of S. mansoni in liver with surrounding epitheloid cells and some leucocytic
infiltration (see Plate 1 for more advanced stage).

Fig. 15. Two boys with advanced schistosomiasis mansoni. Note collateral venous circulation in nearest
patient.

lobules. Liver enlargement is common and Sahara and signs of portal hypertension are
splenomegaly often follows the portal hyper- always present in such cases. Anaemia may
tension (Fig. 15). Hepatosplenic schisto- be found when there is splenomegaly and is
somiasis mansoni is more common in more severe after repeated haematemesis.
Brazil and Egypt than in Africa south of the The reaction to the eggs in the liver may
22 Chapter 1

Fig. 16. ‘Symmer’s clay pipestem’ fibrosis caused by eggs of S. japonicum surrounding portal veins in liver.

eventually cause the periportal fibrotic distributed throughout the body, and the
reaction termed ‘Symmer’s clay pipestem’ greater longevity of the adult worms.
fibrosis (Fig. 16). Liver function tests, how- Brain involvement is most common in S.
ever, are not altered in schistosome fibrosis, japonicum infections and two types of brain
as they are in true cirrhosis, and, although lesions have been reported. In the first type
there may be severe pathological lesions, there is diffuse involvement with scattered
there is no liver failure. Severe disease, lesions, probably caused by eggs being car-
with hepatosplenomegaly, occurs in about ried to the brain in the bloodstream, and
10% of cases of schistosomiasis mansoni, this type usually results in no symptoms. In
but takes 5–15 years to develop, and in the second type a localized granulomatous
children infection can have effects on nutri- mass is present, containing large numbers of
tion (Stephenson, 1993). eggs deposited by ectopic adult worms in
As the portal pressure increases, a the blood-vessels of the brain. These granu-
collateral venous circulation becomes lomas can cause a wide range of symptoms,
established and severe or even fatal depending on the anatomical location of the
episodes of bleeding can result from the lesion in the brain.
oesophageal varices. The portal systemic A transverse myelitis can result from the
shunt results in the eggs bypassing the presence of eggs in the spinal cord and is
liver and being deposited in the lungs. An most commonly found in infections with S.
obstructive and destructive arteritis may mansoni and S. haematobium.
follow, which can lead to systematic arter- In order for the eggs to make their way
ial hypertension and eventually to hyper- through the tissues into the gut, the
trophy of the right ventricle. miracidia release proteolytic enzymes and
The adult worms in the blood-vessels do other material, which diffuses through
little damage when living but their death pores in the eggshell. This material (solu-
can lead to focal necrosis of the liver cells ble egg antigen (SEA)) is highly immuno-
and to granulomas. The more severe genic, and the immune response made
pathology thought to be produced by infec- against it leads to the formation of the large
tion with S. japonicum is usually granulomas that are responsible for most of
explained by the greater egg production, the pathology in this phase. Evidence for
the spherical shape of the egg lacking a this and analysis of the mechanisms involved
large spine resulting in more eggs being have come largely from experiments in
 The Trematodes 23

mice. Granulomas can be induced in the occur against these species (Wilkins et al.,
lungs of mice by intravenous injection of 1984, 1987; Butterworth, 1998; Kabatereine
eggs, and this process is prevented by et al., 1999), and studies in Brazil link resis-
immunosuppressive treatments that inter- tance to particular genetic characteristics
fere with cellular responses. The degree of (Abel and Dessein, 1997). Infections with S.
response to eggs and the pathology that japonicum do not show this picture,
results, following infection in mice, are although there appears to be an age-related
strongly influenced by genetic factors, and reduction in pathology (Ross et al., 2000).
this also reflects different degrees of The slow acquisition of immunity against S.
immune responsiveness. It has recently haematobium and S. mansoni correlates
been shown in humans that at least some with a change in the balance between
of the variation in pathology seen in antiparasite immunoglobulin E (IgE) and
infected populations is due to the activity IgG4, the former promoting protective
of particular major genes, which are associ- responses against incoming larvae, perhaps
ated with T-cell function (e.g. a codomi- by antibody-dependent cellular cytotoxic
nant major gene, SM1, on chromosome 5). (ADCC) mechanisms directed against anti-
The immunology of granuloma formation gens expressed on the surface tegument. As
is complex and involves the activity of shown by work carried out in the 1960s,
both major subsets of CD4+ T-helper (Th) adult schistosomes are largely unaffected by
cells. SEA is a powerful inducer of Th2 immunity and continue to survive in hosts
responses, but Th1 cells also play a role. immune to larval stages (concomitant immu-
The cellular response is initiated and con- nity). One way in which this is achieved is
trolled by the cytokines released and in by the adult schistosomes masking the for-
mice the phenomenon of immunomodula- eign nature of their surface antigens by
tion occurs – i.e. early granulomas tend to incorporating host-derived molecules into
be much larger than those formed later in the tegument and by rapid replacement of
infection. the tegument (antigenic disguise).
Antigen–antibody complexes have been Schistosomes, like many other helminths,
shown by fluorescent antibody studies to exert profound effects on the host’s immune
be the cause of the Splendore–Hoeppli response. Not only do these parasites tend to
phenomenon that occurs in sensitized polarize the T-cell response selectively
hosts. Glomerulonephritis has been towards Th2 activity, but they may also
reported as an immune-complex disease in modulate other components in ways that
schistosomiasis mansoni. result in a more general suppression of
immune and inflammatory responses.
IMMUNOLOGY OF SCHISTOSOMES Immunomodulation can influence the
Although it has been established for many ability of the host to respond successfully
years that laboratory animals, including pri- to other infections, and there is recent evi-
mates, develop immunologically mediated dence that schistosomes and soil-transmit-
resistance to experimental infections, defi- ted nematodes may increase susceptibility
nite proof that acquired immunity to schisto- to both AIDS and tuberculosis (Bundy et
some infections occurs in humans has been al., 2000).
very difficult to demonstrate. It is clear that
intensity of infection and prevalence with S.
DIAGNOSIS
haematobium and S. mansoni is greatest in
10–14-year-olds and declines in older age- Parasitological. The presence of eggs in the
groups, but this could be explained by a faeces or urine is still the most widely used
decrease in water contact. However, longitu- method of diagnosis. This usually poses no
dinal studies and detailed monitoring of problems in heavy infections but diagnosis
reinfection after elimination of an existing may not be so easy in light infections, as
infection by chemotherapy have demon- occur in the majority of cases, particularly
strated that age-dependent resistance does in tourists, who have probably been infected
24 Chapter 1

only once. In general, it is only the presence each species more accurate estimates are
of eggs containing live miracidia that possible (Guyatt et al., 1999).
indicates an active infection requiring treat- Portable ultrasound can be used for
ment. diagnosis of the degree of pathology, partic-
The eggs of S. haematobium, which occur ularly in the liver or bladder, and can
in the urine, can be detected by sedimenta- screen populations at the community level;
tion of a 10 ml sample (best collected around it can also be used for determining the
midday) in a urinalysis flask, the deposit effect of chemotherapy (Hatz, 2000).
being examined under the microscope for
eggs. Alternatively, a 10 ml sample can be Immunological. There are numerous
passed through a polycarbonate or poly- immunological tests for diagnosis but those
amide membrane, washed, removed and involving various ELISA and immunoblot-
stained in 1% trypan blue (or 2.5% ninhy- ting techniques are the most convenient. A
drin, 5% iodine, eosin or methylene blue) dipstick ELISA for urine samples, using an
for a few minutes. After washing again (and SEA can effectively diagnose schistosomia-
drying at 37°C if wished), the filter is exam- sis and correlates well with quantitative
ined in a few drops of saline on a micro- egg counts. Circulating cathodic antigen
scopic slide. It is probably not wise to reuse (CCA) is the dominant antigen in the urine
filters. In about 5% of patients, eggs may also of S. mansoni patients and can be detected
be found in the faeces. by a monoclonal antibody (mAb) of 41/42
Cytoscopy may be performed as a final kDa. There are also circulating soluble
diagnostic measure when no eggs can be adult-derived antigens (Sm31/32 and
found in the urine, but the danger of Sj31/32) in serum, which can be detected
secondary infection makes this a possibly by dot ELISA, and an IgG ELISA can be
hazardous procedure. used to detect antibodies against them.
The eggs of the other species occur in
the faeces and concentration techniques, TREATMENT
such as the formol–ether or Kato–Katz Chemotherapy. Praziquantel (usually in a
thick-smear methods (p. 258), are necessary. single oral dose of 40 mg kg1) is the drug of
A modification of the thick-smear method choice for all species of schistosome and has
can be used for quantitative determinations virtually superseded almost all the agents
and, in some studies, has given a good previously used. It has few side-effects
indication of the number of adult worms, (except sometimes in patients with very
as can filtration staining techniques. In the heavy worm loads), although it is probably
latter, eggs from faeces are stained with better not to give it during early pregnancy.
ninhydrin on filter-paper and counted. Praziquantel is a heterocyclic pyrazine-
Rectal biopsy is often effective (even in isoquinoline unrelated to other
about 50% of cases of S. haematobium), an anthelminthics – chemical formula 2-(cyclo-
unstained squash being examined under hexylcarbonyl)-1,2,3,6,7,11-b-hexahydro-4H-
the microscope. pyrazino[2,1a]isoquinolin-4-one. It is quickly
metabolized, crosses the blood– brain barrier
Clinical. In the field, haematuria can provide and appears to act by causing spastic paraly-
a quick and inexpensive indicator of urinary sis and vacuolization of the tegument of the
schistosomiasis; microhaematuria (measured worm, possibly from interference with inor-
by means of a reagent strip) or proteinuria ganic ion transport and an increase in mem-
correlates well with the intensity of infec- brane permeability; it may also destroy
tion. Even self-reporting by children can lysosomes. Two target antigens are also
provide a useful epidemiological record of affected (a surface tubercle glycoprotein of
community prevalence, although this is 200 kDa and an esterase of 27 kDa) and
likely to give an overestimate, depending on maybe epitopes become exposed so that the
the species of worm and level of infection drug evokes an effective immune response
(Ansell and Guyatt, 1999); using models for (Brindley, 1994; Dupre et al., 1999).
 The Trematodes 25

Metrifonate is cheap and safe to use recently (Chitsulo et al., 2000).

against S. haematobium infection. Its main
disadvantage is that repeated treatment is S. japonicum. China 1.06 (0.09% of total
necessary (usually 7.5–10 mg kg1 given population), Philippines 0.43 (0.6%),
orally in each of three doses at fortnightly Indonesia (Sulawesi) 0.0002 (0.0001%),
intervals). As an organophosphate com- Thailand very rare (‘S. japonicum-like’).
pound, it inactivates the enzyme, destroy-
ing acetylcholinesterase, but its mode of S. mansoni. Antigua fewer than 0.0001*,
action against the worms is obscure. Brazil 7.01 (4%), with a mortality rate of
Atropine sulphate can be used if symptoms 0.44 per 100,000, Burundi 0.84 (13%),
of cholinergic activity occur. Dominican Republic 0.23 (3%), Eritrea 0.26
Oxamniquine is a tetrahydroquinoline (7%), Guadeloupe 0.033 (8%)*, Martinique
derivative that has activity only against S. 0.005 (1.3%)*, Puerto Rico 0.015 (0.4%)*,
mansoni (given at a single oral dose of 15 St Lucia 0.0019 (1.2%)*, Rwanda 0.38
mg kg1 ) and can be used for advanced (6%), Surinam 0.0037 (0.9%) and rising in
cases of the disease. It should be avoided children, Venezuela 0.0338 (0.2%).
in early pregnancy and in cases of epilepsy,
and can cause drowsiness. Resistance to S. haematobium. Algeria 2.1 (7.5%), India
the drug has also been reported, and it is in (Bombay area) very rare, Iran 0.042
limited supply. The mode of action is (0.07%), Iraq 0.042 (0.2%), Jordan 0.0001
unknown. (0.002%), Lebanon very rare*, Libya 0.27
The antimalarial compound artemether (5%), Mauritius 0.016 (1.5%)*, Syria 0.003
or artesunate (oil and water soluble forms (0.02%)*, Turkey 0.0006 (0.001%)*.
of an artemisinin derivative) is being tested
as a prophylactic against S. japonicum in S. mansoni and S. haematobium. Angola 4.8
China and in one trial was shown to reduce (44%), Benin 1.95 (35%), Botswana 0.15
egg production of S. mansoni and S. (10%), Burkina Faso 6.24 (60%), Cameroon
haematobium by 15% after 12 weeks when 3.02 (23%), Central African Republic 0.33
given in the usual dose for malaria. It also (10%), Chad 2.78 (43%), Congo 0.89 (34%),
acts principally against developing worms, Congo Republic (Zaire) 13.84 (28%), Côte
unlike the two compounds at present in d’Ivoire 5.6 (40%), Egypt 10.06 (17%),
use; cyclosporin has similar modes of Equatorial Guinea 0.008 (2%), Ethiopia 4.0
action but would be too expensive for gen- (7%), Gabon 0.5 (45%), Gambia 0.33 (30%),
eral use. Caution needs to be exercised in Ghana 12.4 (73%), Guinea 1.7 (26%),
relation to malaria resistance. Guinea Bissau 0.33 (30%), Kenya 6.14
(23%), Liberia 0.648 (24%), Madagascar
Surgery. In advanced cases with liver fibro- 7.54 (55%), Malawi 4.2 (43%), Mali 5.88
sis, portocaval shunt and occasionally (60%), Mauritania 0.63 (27%), Mozambique
splenectomy have been used to relieve the 11.3 (70%), Namibia 0.009 (0.6%), Niger
portal hypertension, but the results have 2.4 (27%), Nigeria 25.83 (23%), Senegal 1.3
been disappointing. (15%), Sierra Leone 2.5 (60%), South Africa
4.5 (11%), Swaziland 0.23 (26%), Togo 1.03
EPIDEMIOLOGY (25%), Uganda 6.14 (32%), Tanzania 15.24
Schistosomiasis, particularly when due to (51%), Yemen 2.23, Zambia 2.39 (27%),
S. haematobium, is very much a focal dis- Zimbabwe 4.4 (40%).
ease and many prevalence figures are based
on limited surveys, which are not always S. intercalatum. Cameroon locally in forest
typical of the country as a whole. However, areas, Congo (16% in children in one area),
estimates in millions of overall prevalence Congo Republic (Zaire) sporadic,
in each endemic country have been made Equatorial Guinea (13% in Bata city),

*It is probable that in these countries transmission has now ceased and these are residual cases.
26 Chapter 1

Gabon (29% in one area), São Tomé and munity that has levels of egg output likely
Principe 0.005 (4%). Confirmation needed to cause morbidity (Jordan et al., 1993).
for presence in Central African Republic, This demonstrates the importance of quan-
Chad, Mali and Nigeria. titative determinations of egg output in
schistosomiasis (p. 260). The ecological fac-
S. mekongi. Cambodia 0.07 (0.7%), Laos tors associated with the transmission of
0.12 (2%) and recent cases in refugee schistosomiasis vary markedly with the
camps in Thailand. species of schistosome, owing to the differ-
ing habitats of the snails involved. The
S. malayensis. Malaysia very rare (Shekar, amphibious snail hosts of S. japonicum live
1991). mainly in rice paddies and muddy habitats
beside rivers; the aquatic snail hosts of S.
In most areas endemic for S. haematobium mansoni live principally in gently flowing
there is a very high prevalence rate, with running water (less than 0.3 m s1 ) such as
almost everyone in the community lightly irrigation channels, streams, lakes and
infected before the age of 10 years. Studies ponds (Plate 2); those transmitting S.
in Brazil, St Lucia, Tanzania and Uganda haematobium live almost entirely in still
demonstrated a relationship between egg water, such as ponds, pools, lakes and
output and prevalence of S. mansoni in marshy areas. Snail populations usually
children (Fig. 17). Above 50–60% preva- show marked seasonal fluctuations, the
lence, a small extra rise is accompanied by most important factors influencing numbers
a considerable increase in egg output and being rainfall and temperature. The effect
thus in the severity of disease. Post-mortem of rainfall varies, depending on the yearly
studies and blood-filtration studies after rainfall figures. In drier regions of Africa
chemotherapy for counting adults have rainfall stimulates the production of young
shown a good relationship between the last bulinid and planorbid snails, while in
two parameters so that intensity of infec- equatorial regions with a higher rainfall,
tion can be expressed in terms of eggs per snails are washed away during the rainy
gram of faeces or per 10 ml of urine. To season and breeding takes place principally
determine the intensity of infection of dif- in the months following. Temperature is
ferent age-groups, the frequency of occur- another factor limiting population densi-
rence of the different levels of egg output ties, the temperature range for optimal
can be conveniently plotted and provides a expansion of snail numbers being
good indicator of the proportion of the com- 20–28°C.

100 x ZAIRE

x KENYA
Prevalence (%)

75 x EGYPT
x BRAZIL
x ST LUCIA x ZAMBIA

50 x KENYA
x ETHIOPIA
x BURUNDI
x BURUNDI

25
x ETHIOPIA

200 400 600 800

Geometric mean of egg output (e.p.g. faeces)

Fig. 17. Relationship between overall prevalence and intensity of S. mansoni infection as determined by
egg output (measured by Kato–Katz technique) in various endemic areas. Each determination is based
on studies by different workers. e.p.g., eggs per gram. (From Jordan et al., 1993.)
 The Trematodes 27

Seasonal variations in the cercarial trans- hemisphere B. glabrata is the most impor-
mission rates in snails are most marked with tant snail host, with seven other species
the bulinid hosts of S. haematobium living locally involved.
in temporary bodies of water. In hyper-
endemic habitats, such as canals, there may S. haematobium. Bulinus is a turreted pul-
be large numbers of snails producing cer- monate snail with a left-handed opening
cariae of S. mansoni throughout the year. when looked at with the spire upwards
Diurnal fluctuations in the production (Fig. 1). The height varies from 4 to 23 mm.
of cercariae occur; cercariae of S. japon- The subgenus B. (Physopsis) is differenti-
icum (which is adapted for transmission ated from B. (Bulinus) by having a truncate
among the nocturnal animal reservoir columella and a pointed end to the foot in
hosts) are mostly produced in the evening, living specimens. Two main groups of
while those of S. mansoni and S. haemato- bulinid snails are important as hosts: (i) the
bium are produced in the middle of the africanus group (ten species) of the sub-
day. This factor is not usually of practical genus Physopsis is the more important
importance except where S. mansoni trans- group in eastern and southern Africa and
mission occurs in running water, in which in most parts south of the Sahara; and (ii)
case washing and bathing are likely to be the truncatus, forskali and reticulatus
much safer in the morning and evening, groups (27 species) of the Bulinus sub-
when cercariae are less abundant. genus of snails act as hosts in the Near East
(Iran, Egypt and Sudan), in Madagascar
SNAIL HOSTS OF SCHISTOSOMES and in parts of both East and West Africa.
S. japonicum. Oncomelania is a conical,
amphibious, prosobranch snail measuring S. intercalatum. B. (Physopsis) africanus acts
3–10 mm and having 4–8 whorls, a dextral as snail intermediate host in Congo Republic
opening and an operculum covering the foot. and B. (Bulinus) camerunensis in Cameroon.
Species involved are O. hupensis from main- It must be borne in mind when attempting
land China, O. nosophora from south-west to identify a snail that there are usually
China (and Japan), O. formosana from many other types of snail present in the
Taiwan, O. quadrasi from the Philippines same body of water as the ones transmit-
and O. lindoensis from Sulawesi. ting schistosomiasis, and they may be
difficult to differentiate. Specialized mono-
S. mekongi. Neotricula aperta is an aquatic graphs need to be consulted (Brown, 1980)
snail found in the Mekong River and it or expert advice sought. It is also important
probably also transmits S. sinensium. to distinguish clearly the cercarial species
Robertsiella spp. are found in Malaysia and emerging, because of the large number of
transmit S. malayensis. animal and bird schistosomes that use the
same snail hosts and produce cercariae
S. mansoni. Biomphalaria is a flattened pul- similar to the human schistosomes. In
monate, planorbid snail with 3.5–7 whorls, detailed epidemiological studies, it may be
measuring 7–22 mm. Four main groups are necessary to expose laboratory animals to
found in Africa: (i) the pfeifferi group (four the cercariae and to identifiy any adult
species), which include the most important schistosomes that develop.
hosts in Africa and the Middle East; (ii) the
sudanica group (three species), which occur
in both East and West Africa; (iii) the PREVENTION AND CONTROL
choanomphala group (three species), which Personal prevention is by avoidance of
live in the great lakes and act as hosts in water sources containing cercariae, impos-
Lake Victoria; and (iv) the alexandria group sible for fishermen to carry out and
(two species), which occur sporadically in extremely difficult for children to be con-
North, East and South Africa. In the western vinced of the necessity thereof. The most
28 Chapter 1

common source of infection in tourists to the intensity of transmission is also impor-

Africa appears to be swimming in Lake tant. Campaigns have been carried out in
Malawi. Thorough and speedy towelling many countries, often with great success,
after swimming or wading in marshes may and at the outset are vertical, involving spe-
prevent cercariae from penetrating. cialized control units that have identified
Before attempting any control measure, and mapped transmission sites, assessed the
it is essential to define its objectives – i.e. level of morbidity and educated health
whether it is intended to prevent apread of workers and the community about the con-
the disease, to reduce morbidity or trans- trol programme (WHO, 1993; Savioli et al.,
mission or to permanently interrupt trans- 1997). Later, community-based control pro-
mission (elimination in an area or grammes can be instigated, utilizing trained
eradication in a country or worldwide). community health workers. If transmission
Until the aims of a project have been is intense (over 50% in children), then the
clearly defined, it is difficult to work out whole population can be treated; otherwise,
techniques and costings, or even to evalu- 7- to 14-year-old schoolchildren can be
ate its eventual success. While eradication targeted, since they can be easily tested,
must be the ultimate objective, it is not yet treated and followed up and are likely to be
a feasible proposition in many areas. the most heavily infected section of the pop-
There are five principal methods of con- ulation. A small number of heavily infected
trol: mass chemotherapy, destruction of
individuals produce a large percentage of
snails, environmental sanitation, preven-
the eggs reaching the environment (in one
tion of water contact and the possible use
classic study with S. mansoni, 51% of
of mass vaccination. Which method or
patients had fewer than ten worm pairs
methods are to be employed will depend
while only 7% had more than 80 – although
very much on the conditions where they
one girl who died had 1600 worm pairs). In
are to be applied but it is usually essential
all campaigns periodic re-treatment is
to provide alternatives or to use two or
essential in order to have a lasting effect.
more methods simultaneously (e.g.
chemotherapy, snail control and health After campaigns with praziquantel in China,
education). It is also important to deter- Indonesia and the Philippines, reduction in
mine at the beginning how the success of the size of the liver and spleen was reported
the campaign is to be measured, and vari- (WHO, 1993), while in patients with schisto-
ous indices can be used. The most common somiasis mansoni, hepatomegaly and peri-
assessment is that of prevalence, but inci- portal fibrosis have regressed after treatment
dence (measurement of the rate at which as measured by ultrasound (Boisier et al.,
people become infected) is more sensitive 1998; Frenzel et al., 1999).
and is particularly useful in mass
chemotherapy campaigns. Other measures CONTROL OF SNAILS
of assessment that can be used are the
effect on egg output (i.e. on intensity of Chemical control. The relationship between
infection) or on severity of clinical disease the population dynamics of snail interme-
(morbidity), immunological methods and diate hosts and disease transmission to
various indirect biological methods. The humans is poorly understood and complete
most common biological method of assess- eradication of snails from large areas is not
ing the success of measures against the feasible. Mollusciciding is likely to be most
intermediate host is a periodic snail count effective in targeted focal sites, say where
but determinations of the infection rates in children habitually bathe. Infection van-
snails have been used. ished from Tunisia in 1983 after treatment
of oases.
Mass (universal) chemotherapy. The primary Niclosamide (Bayluscide) can be used at
objective should be the reduction and pre- a concentration of 8 p.p.m. hours (e.g. 0.33
vention of morbidity, although a decrease in p.p.m. for 24 h) for aquatic snails (Plate 3)
 The Trematodes 29

or 0.2 g m2 on moist soil for amphibious avoiding contaminated water needs to be
hosts of S. japonicum. effectively communicated, particularly to
children and adolescents. While it is prob-
Biological control. Carnivorous snails, such ably impossible in Africa to prevent chil-
as Marisa cornuarietis, or competitors, dren swimming in the water, they could be
such as Melanoides tuberculata and taught to urinate (and perhaps defecate)
Tarebia granifera, have been added to habi- before entry.
tats in Guadeloupe, Martinique, Puerto
Rico and St Lucia, with the result that Present position and future outlook for con-
Biomphalaria has vanished from all or trol. Present control methods are capable of
almost all areas (Giboda et al., 1997; substantially reducing transmission and
Pointier and Jourdane, 2000). particularly morbidity in most areas pro-
vided that they are properly designed and
Ecological methods of control. Habitats can carried out and if adequate funds are avail-
be made unsuitable for snails by alternate able. However, new irrigation and hydro-
flooding and drying of water channels or electric schemes in many endemic
covering and lining of canal systems, as in countries have increased the number of
Egypt and Sudan, and filling in of marshy snail habitats. New human-made lakes
areas. In many areas such measures are have followed the building of dams in
likely to be permanently successful, but many countries: Côte d’Ivoire (Lakes
they require close cooperation between Kossou and Taasbo), Egypt and Sudan
irrigation engineers and public health (Lake Nasser); Ghana (Volta Lake); Nigeria
workers. In rice-growing areas of mainland (Kainji Lake); Zambia and Zimbabwe (Lake
China and in Leyte Island (Philippines) Kariba); Senegal (Lake Guiers below the
widespread cleaning of irrigation ditches Diama dam and Manantali dam in Mali).
and filling in of ponds have resulted in a The incidence of schistosomiasis in the
great reduction in schistosomiasis japon- populations bordering these lakes or the
icum infection in recent years. irrigation channels coming from them (as
in Egypt and the Gezira scheme in Sudan)
Prevention of water contact. The provision almost always rises. In Côte d’Ivoire
of piped water supplies and alternative around Lake Kossou there used to be an
bathing and clothes-washing places can be infection rate of 14% with S. haemato-
effective in preventing human contact with bium, which has now risen to 53%, and
infested water and, while expensive, does around Lake Taabo the rate has risen from
have wide-ranging health benefits. 0% to 73% (although the 2% infection rate
For visitors and tourists, prevention can with S. mansoni has not changed so far);
be achieved by avoidance of contact with around Lake Kainji the infection rate with
water in ponds, canals, slow-flowing S. haematobium is now 14% in children
streams and the shallow edge of lakes in (from nothing); around Lake Kariba there is
endemic areas (although in Lake Victoria in now a 70% infection rate in children with
East Africa the snail Biomphalaria S. haematobium; infection has spread
choanomphala transmits S. mansoni in greatly in the Senegal River basin since the
water 2 m deep). For tourists, swimming in building of the dams and there is now a
Lake Malawi or Lake Kariba is often fol- prevalence of 91% with S. mansoni (from
lowed by infection. Dibutyl phthalate or 1%) and of 28% with S. haematobium
hexachlorophene spread over the skin will (Southgate, 1997). One trend in Africa
protect for about 4 h. caused by changes in ecology following the
building of dams in Africa (e.g. in delta
Health education. Knowledge of the role of areas of Cameroon, Ghana and Egypt) is the
indiscriminate defecation and urination in replacement of S. haematobium by S. man-
spreading the disease to members of a com- soni. The new opportunities for agriculture
munity and the personal importance of are also attracting possibly infected
30 Chapter 1

migrants and this is particularly apparent Progress to date indicates that a vaccine is
in the Gezira and in Ethiopia (although the feasible, since protection against sheep
building of the Koka dam initially reduced schistosomiasis (a problem in Sudan) using
transmission). irradiated cercariae has been successfully
Infection has been eliminated from achieved. However, any human vaccine
Japan, Tunisia and Montserrat recently and will have to consist of defined components,
campaigns against S. haematobium are as cercariae might introduce viruses.
being mounted in Mauritius (1.3% in adults Various types of vaccine are being inves-
only), Morocco (2.3% overall) and Tanzania tigated (Capron, 1998). These include the
(45% in Zanzibar), against S. mansoni in following.
Brazil, Burundi, St Lucia and Venezuela
1. Peptide components of protective anti-
(risen from 0.1% to 0.9% in under-10-year-
gens. These can be used to generate
olds in the last few years) and against both
differential responses, e.g. one elicits
species in Egypt, Ghana, Madagascar,
eosinophil-dependent ADCC, another stim-
Malawi, Mali, Nigeria, Saudi Arabia, Sudan
ulates delayed-type hypersensitivity (DTH)
and Zimbabwe; against S. japonicum in
reactions with macrophage activation.
China, Indonesia (1% overall infection rate)
and the Philippines (3.6%); and against S. Recently a multiple antigen peptide (MAP)
mekongi in Laos (72%) (WHO, 1993). vaccine has shown very promising results,
China has had control campaigns involv- inducing both T-cell and B-cell responses
ing mass treatment of people and cattle with in mice and in monkeys, reducing parasite
anthelminthics (nowadays praziquantel), fecundity and egg viability and decreasing
snail control and environmental engineering liver pathology by over 70%.
for the last 50 years but there were still esti- 2. Excretory/secretory (ES) antigens. ES
mated to be 1.06 million cases in humans material obtained from postcercarial schisto-
and 0.25 million cases in cattle in 1997. somula kept in vitro is effective in immu-
However, S. japonicum has been eliminated nizing rats to subsequent infection. The
from 150 of the formerly 378 endemic coun- secretions contained proteins in the range
ties in 12 provinces south of the Yangtze 22–26 kDa (amplified by PCR) and induce
River (Ross et al., 1997), while in 1955 there an IgE-dependent ADCC.
were estimated to be over 11 million cases. 3. Membrane antigens. Molecules with a
Unfortunately, recent flooding has increased molecular weight of 23 kDa (e.g. Sm23 and
the extent of snail habitats. The Three Sj23) occur in the tegument of all stages of
Gorges dam under construction on the the parasite but are often species-specific.
Yangtze River will, within the next 10 years, 4. Paramyosin. This 97 kDa internal anti-
create the largest lake in the world in a gen (e.g. Sm97), obtained from schisto-
highly populous region where schistosomia- somula or adults, induces responses that
sis japonicum already occurs and where affect the muscles and tegument of adults
there will have to be about 2 million extra (Gobert, 1998).
migrants from highly endemic areas, which 5. DNA vaccines. Direct injection of the
will be flooded. The building of the dam coding sequence for known antigens is
should reduce the overall density of snails being investigated. Such a vaccine can be
along the river banks but will provide many used alone or combined with chemother-
more suitable, contaminated, marshland apy, e.g. immunization with DNA for Sm28
habitats and an increased contact with water. glutathione-S-transferase (GST) together with
praziquantel prevented the formation of
Towards a vaccine. The need for a vaccine pathological lesions in mice (Dupre et al.,
against schistosomiasis is underscored by 1999).
the fact that, although chemotherapy with 6. Irradiated live cercarial vaccines.
praziquantel is very effective, in the Although these are not directly suitable for
absence of an effective immune response human use, they might provide useful
reinfection tends to occur quite quickly. pointers to promising leads (Coulson, 1997).
 The Trematodes 31

The most promising six antigens were on the island of Leyte in the Philippines,
recently selected by the World Health although many other species of animals are
Organization (WHO) for testing as vaccines infected, as they are on Sulawesi (Indonesia)
but at best gave only a maximum of 60% and used to be in Japan. Molecular studies
protection (Katz, 1999). indicate that S. japonicum is a species com-
A general problem facing the develop- plex of many sibling species, and in Taiwan
ment of vaccines against any infectious dis- the local form of S. japonicum occurs only
ease is the generation of an appropriate in animals and is not infective to humans.
T-cell response (e.g. CD4+ or CD8) and, if The dog appears to be the only reservoir host
CD4+, then the appropriate Th subset, Th1 of S. mekongi in Laos. S. sinensium is a little
or Th2. In addition, where the disease asso- known species with a laterally spined egg
ciated with infection is immune-mediated, found a few times in humans and rodents in
as in schistosomiasis, vaccination must not China and Thailand (Greer et al., 1989),
induce pathological responses. There is while the ‘Tonle Sap schistosome’ has been
controversy about whether Th1 or Th2 newly discovered in humans living around
responses are most important and appro- Lake Tonle Sap in Cambodia (Pecoulas et al.,
priate for vaccine-induced resistance to 1995).
schistosome infection, but it is probable S. mansoni has been reported frequently
that a balanced response would be best from animals (of 38 species) but in many
(Wynn and Hoffmann, 2000). cases they do not appear to have any epi-
The route of administration of any vac- demiological significance. However, baboons
cine is also very important, as is the choice and green monkeys are apparently main-
of a suitable adjuvant. Presentation of anti- taining infections among themselves in
gens via an engineered vector organism can areas of East Africa and rodents may act as
overcome both problems. For example, reservoir hosts in East Africa, Senegal and
Bacillus Calmette–Guérin (BCG) has been Guadeloupe and particularly in Brazil,
engineered to produce an intracellular where up to 15 species appear to be of
schistosome GST and this has induced a increasing importance in maintaining
strong and long-lasting response in mice infection in urban and periurban areas of
when given by the intranasal route (a the north-east (Mott et al., 1995).
mixed response of GST-specific immuno- Animals appear to be of little or no
globulin – IgG2a, IgG2b and IgA in serum importance in the transmission of S.
and IgA in bronchial lavage fluids). A vac- haematobium, although various primates
cine against schistosomiasis haematobium have been found infected, nor are they for
(Sh28GST – Bilhvax) together with prazi- S. intercalatum.
quantel treatment is undergoing field trials The schistosomes found in humans and
in Senegal. animals in Africa can be divided into two
groups of sibling species. Hybridization
ZOONOTIC ASPECTS can occur experimentally within members
Animal hosts are extremely important in the of each group but is not common in nature.
transmission of S. japonicum and S. In the S. haematobium/S. intercalatum
mekongi and in some countries can maintain group, S. mattheei Veglia and Le Roux,
the parasite in the absence of humans. In 1929, is a parasite of sheep, cattle, wild
mainland China infection occurs in 40 animals and occasionally humans in south-
species of domestic and wild animals ern Africa. The eggs in the faeces or urine
(Jordan et al., 1993) and is important as a have a terminal spine and measure
serious cause of morbidity and mortality in 120–180 µm in length (Fig. 124). Curiously,
cattle and goats. In the Dongting Lake area of in all human cases, the eggs have occurred
Hunan, 60% of cattle and buffaloes, 24% of together with those of S. haematobium or
pigs, 9% of dogs and 7% of people were S. mansoni; the females of S. mattheei are
found to be infected. Dogs and pigs play an known to be capable of producing eggs
important part in maintaining transmission parthenogenetically and are perhaps carried
32 Chapter 1

by excess males of the other species. S. Family Paragonimidae

bovis (Sonsino, 1876) Blanchard, 1895, is
similar to S. haematobium and is found in Paragonimus westermani
cattle in southern Europe, in Iraq and over (Kerbert, 1878) Braun, 1899
much of Africa, but there have been very
few genuine infections in humans SYNONYMS
(Mouchet et al., 1988). S. margrebowiei Le Distoma westermani (D. westermanii)
Roux, 1933, is a common parasite of Kerbert, 1878; D. ringeri Cobbold, 1880.
antelopes in Africa but the few human
cases reported might be spurious. S. rod- DISEASE AND COMMON NAMES
haini Brumpt, 1931, is closely related to S. Paragonimiasis or paragonimosis; pul-
mansoni and is found in rodents and carni- monary distomiasis, Oriental lung fluke
vores in Central Africa; it has been infection.
reported once from a human. S. curassoni,
Brumpt 1931, is a parasite of domestic LOCAL NAMES
ruminants in West Africa and has been Pa-yard bai-mai nai pod (Thai).
doubtfully reported from humans.
The cercariae of various mammal and GEOGRAPHICAL DISTRIBUTION
bird schistosomes penetrate the skin of Paragonimus westermani is widely distrib-
humans in many areas of the world but do uted in the Chekiang Province of China,
not develop further. In a sensitized host Korea, Laos, the Philippines, Taiwan and
they cause dermatitis at the site of entry, Thailand and also occurs in smaller areas of
with irritation, pruritus, macules and India, Indonesia, Japan, Malaysia and
papules (‘swimmers’ itch’ or ‘schistosome Vietnam, with one or two cases in Russia
dermatitis’). Examples are the cercariae of and Poland. Although there are at least 14
the bird parasites Austrobilharzia terri- other species that have been reported from
galensis (Australia), Bilharziella polonica humans, most of the estimated 21 million
(Europe), Gigantobilharzia sturniae (Japan), cases in 39 countries worldwide are due to P.
G. huttoni (Florida, USA), Microbilharzia westermani, with 195 million people at risk.
variglandis (Delaware, USA), Tricho-
bilharzia brevis (Japan), T. maegraithi LOCATION IN HOST
(Thailand), T. ocellata (worldwide) and T.
The adults are typically found in pul-
stagnicolae (USA) and cercariae of mam-
monary cysts, usually in pairs.
malian species of schistosomes, such as
Heterobilharzia americana (Louisiana,
MORPHOLOGY
USA), Orientobilharzia turkestanica (China
A living Paragonimus is a thick fleshy fluke
and Iran), Ornithobilharzia turkestanicum
measuring 8–16
4–8 mm and is reddish-
(Iran), Schistosoma bovis (Africa), S. spin-
dale (Asia) and Schistosomatium douthitti brown in colour, with a tegument covered in
(North America). simple or toothed spines. The ventral sucker
Schistosome dermatitis is more of a nui- lies just anterior to the middle of the body
sance than a serious medical problem and is about the same size as the oral sucker.
when it occurs in bathers or water-sports The testes are almost side by side in the pos-
enthusiasts using lakes frequented by terior part of the body. The large excretory
waterfowl, but is of real economic impor- bladder is usually apparent in sections of
tance among rice planters in China, the worm (Fig. 18 and Plate 4). The yellow-
Malaysia and Vietnam. ish-brown egg is ovoid and thick-shelled. It
measures 80–110 µm
50–60 µm, with a
rather flattened operculum, which gives the
impression of being too small, and is unem-
bryonated when laid (Fig. 123).
 The Trematodes
Map 3. Distribution of Paragonimus spp. and Opisthorchis felineus.

33
34 Chapter 1

LIFE CYCLE the water, where they can survive for only
The eggs are usually swallowed and pass 24–48 h.
out in the faeces but may also escape in If cercariae find freshwater crabs, princi-
sputum. For further development they pally Eriocheir, the mitten crab in Asia and
have to reach water. The miracidia hatch also Potamon (Fig. 19) and Sesarma, or
after 3 weeks in water (at an optimum tem- freshwater crayfish (Astacus), they penetrate
perature of 27°C) and penetrate freshwater and encyst in the gills or muscles as meta-
snails. These are operculate genera, of cercariae (measuring 250–500 µm).
which the most important is Semisulcospira Freshwater crustaceans can probably also
(S. libertina is an intermediate host species become infected by ingesting unencysted
in China, Japan, Taiwan and Korea). Other cercariae in the water or even inside an
important snails are S. amurensis, Thiara infected snail.
granifera and Oncomelania nosophora (see The crustacean intermediate hosts are
Fig. 1). eaten by humans as food. If they are eaten
In the snail the miracidia develop into raw, the metacercariae hatch in the duode-
sporocysts followed by two generations of num and young worms penetrate through
rediae, and finally, in about 3 months, give the intestinal wall and pass across to the
rise to very short-tailed cercariae. The cer- abdominal wall in about 6 h. The immature
cariae emerge from the snail and swim in flukes burrow through the diaphragm to the

Fig. 18. Cut portion of lung (of a tiger) with cysts containing pairs of adult Paragonimus. Note large
excretory bladder in each fluke.

Fig. 19. Potamon, a crab second intermediate host of Paragonimus in Asia.

 The Trematodes 35

pleural cavity in 6–10 days and enter the become surrounded by a cyst, possibly
lung capsule in 15–20 days. The first eggs caused by softening followed by fibrosis
are passed 60–70 days after infection. (Plate 4). However, as the cyst wall is usu-
Although Paragonimus is hermaphrodite, ally lined with columnar epithelium, it is
two worms are necessary for fertilization to probable that, in most cases, it represents
take place (Fig. 19 and Plate 4). This is true the expanded wall of a bronchus. The cap-
for the usual diploid form of P. westermani, sule is collagenous and oedematous, with
but there is also a triploid form, in which plasma cells, eosinophils, neutrophils,
parthenogenesis can occur; the adults of the macrophages and fibroblasts. The cyst mea-
latter are larger and more pathogenic and sures about 1 cm in diameter after 90 days
the eggs differ in size and shape (see Blair and is filled with a thick brownish fluid
et al., 1999). The adult worms can live for containing eggs. Bronchopneumonia may
20 years but usually die after about 6 years. result when a cyst bursts or retains an
opening into a bronchus. Eggs are often
CLINICAL MANIFESTATIONS present in the lung tissues and cause
There are no recognizable symptoms pseudotubercles similar to those caused by
accompanying the migratory phases. schistosome eggs, with infiltration by
The first signs are usually fever with a eosinophils and lymphocytes, followed by
dry cough, sometimes accompanied by giant cells and fibroblasts.
bloodstained sputum containing eggs after
rupture of the cysts. Chest pain can be Extrapulmonary. Adults are sometimes
severe and, if the infection is heavy, there found in many parts of the body, particu-
is sometimes increasing dyspnoea and larly in the organs of the abdominal cavity
bronchitis. Many patients with haemo- or subcutaneous tissues. In these sites the
ptysis are diagnosed as suffering from worms are rarely fertilized and presumably
pulmonary tuberculosis. have developed from larvae that lost their
Cerebral paragonimiasis may result in way. This occurs more frequently with
epileptic seizures, as well as headaches, species of Paragonimus which are less
visual disturbances and symptoms of adapted to humans than P. westermani.
meningitis. Most serious complications follow the
presence of flukes in the brain (Fig. 20).
PATHOGENESIS
This may be common in areas of high
Pulmonary. As flukes grow in the lungs endemicity (e.g. over 5000 cases per
they cause an inflammatory reaction and annum in South Korea). Adults found in

Fig. 20. Radiograph of head of a girl with soap-bubble type of calcification surrounding cysts containing
adult Paragonimus in occipital lobes.
Exploring the Variety of Random
Documents with Different Content
 “The hounds bay and the hunt sweeps off in the distance—now lost to sight, and
now emerging from the hollows. The volunteers soon begin to return, and are seen
everywhere straggling about over the slopes. The carriages move on,
accompanying, as they can, the hunt by the road, till it strikes across the country
and is lost. The sunshine beats on the mountains that quiver in soft purple; larks
sing in the air; Brown, Jones, and Robinson ride by the side of the carriages as they
return, and Count Silinini smiles, talks beautiful Italian, and says, ‘Yas.’ He is a
guardia nobile, and comes to the house twice a week if there are no balls, and
dances with Marianne at all the little hops. Signor Somarino pays his court
meanwhile to Maria, who calls him Prince, emphasising the title when she meets
her friends the Goony Browns. And so the hunting picnic comes back to Rome.”

As a writer, Mr Story’s strong point is description of scenery, both

rural and urban. He is excellent at a landscape; and, in the graphic
views he presents to us of Rome’s streets and squares and fountains
and markets, beggars and models, washerwomen and pifferari, he is
a compound of Prout and Pinelli. From the very first page of the
book, one is attracted by the freshness of his vocabulary and the
vividness of his style. With his Cleopatra and Sybil bright in our
memory, we cannot think he mistook his vocation when devoting
himself to sculpture; but certainly the glow and choice of his literary
tints incline us to the belief that, as a painter, he might have been
even more successful. We are unwilling to quote extensively from a
book that will doubtless have been read by many of our readers ere
this notice of it gets into their hands, but there are fifty passages that
we are tempted to extract instead of merely referring to them. The
first short chapter, “Entrance,” contains more than one of these. At
page 11 we have a sketch of a couple of the Abruzzi pifferari, piping
and blowing on their primitive instruments before one of the fifteen
hundred Madonna shrines of Rome—images of the Virgin, with
burning lamps, found in all manner of places, at street corners, down
little lanes, in the heart of the Corso, in the interior courts of palaces,
or on the staircases of private houses—which places the itinerants
before us, in flesh and blood, in their conical hats with frayed
feathers, red waistcoats and skin sandals, wie sie leibten und lebten,
as the Germans say, the old man with a sad amiable face, droning out
bass and treble in an earnest and deprecatory manner, and the
younger vigorous player on the piffero, “with a forest of tangled black
hair, and dark quick eyes that were fixed steadily on the Virgin, while
he blew and vexed the little brown pipe with rapid runs and nervous
fioriture, until great drops of sweat dripped from its round open
mouth. Sometimes, when he could not play fast enough to satisfy his
eagerness, he ran his finger up and down the vents; then, suddenly
lowering his instrument, he would scream, in a strong peasant voice,
verse after verse of the novena, to the accompaniment of the
zampogna (bagpipe). One was like a slow old Italian vettura, all
lumbered with luggage and held back by its drag; the other panting
and nervous at his work as an American locomotive, and as
constantly running off the rails. As they stood there playing, a little
group gathered round. A scamp of a boy left his sport to come and
beat time with a stick on the stone step before them; several children
clustered near; and one or two women, with black-eyed infants in
their arms, also paused to listen and sympathise.”
Every one who has been in Rome during Advent has seen this
group, or one mighty like it and equally characteristic. Turn to the
book (chapter on “Street Music in Rome”) for the little scene that
follows, for the music of the pifferari song, and for Mr Story’s
conversation with the enthusiastic piper, whom, with his
companions, he invited up into his house, where they agreeably
stunned him with their noisy music, to the delight of his children and
the astonishment of his servants, for whom piffero and zampogna
had long since lost all charm, and who doubtless looked upon their
introduction with somewhat of the same feeling of disgust with
which London flunkies would behold that of a couple of organ-
grinders and a cage of white mice into a Grosvenor Square drawing-
room. However, Mr Story took down the words of their quaint song,
which we find printed, probably for the first time, in his book, and he
also got from them some curious particulars of their wanderings. The
man who blew the little brown pipe was quite a character. He and his
companion had played together for three-and-thirty years, and their
sons, who presently came up, were to play together with them. “For
thirty-three years more, let us hope,” said Mr Story.

“‘Eh! Speriamo’ (let us hope so), was the answer of the pifferaro, as he showed
all his teeth in the broadest of smiles. Then, with a motion of his hand, he set both
the young men going, he himself joining in, straining out his cheeks, blowing all
the breath of his body into the little pipe, and running up and down the vents with
a sliding finger, until finally he brought up against a high, shrill note, to which he
gave the full force of his lungs, and after holding it in loud blast for a moment,
startled us by breaking off, without gradation, into a silence as sudden as if the
music had snapped short off like a pipe-stem.”

There are a great many stories and incidents of and relating to

Rome and its inhabitants scattered through the ‘Roba;’ and although
to us “old Romans,” not all of these may be new, the majority of them
will be so to most readers, and they are generally well told and ben
trovate. Amongst them we prefer those little anecdotes and traits of
character which are evidently derived from the writer’s personal
observation, and which, therefore, as might be expected, are amongst
the most racy morsels in the book. Take the following as an excellent
specimen of quiet humour—a strain in which we like Mr Story better
than in his more buoyant mood:—

“My friend Count Cignale is a painter—he has a wonderful eye for colour and an
exquisite taste. He was making me a visit the other day, and in strolling about the
neighbourhood we were charmed with an old stone wall of as many colours as
Joseph’s coat: tender greys, dashed with creamy yellows and golden greens and
rich subdued reds, were mingled together in its plastered stonework; above
towered a row of glowing oleanders covered with clusters of roseate blossoms.
Nothing would do but that he must paint it, and so secure it at once for his
portfolio; for who knows, said he, that the owner will not take it into his head to
whitewash it next week, and ruin it? So he painted it, and a beautiful picture it
made. Within a week the owner made a call on us. He had seen Cignale painting
his wall with surprise, and deemed an apology necessary. ‘I am truly sorry,’ he said,
‘that the wall is left in such a condition. It ought to be painted all over with a
uniform tint, and I will do it at once. I have long had this intention, and I will no
longer omit to carry it into effect.’
“‘Let us beseech you,’ we both cried at once, ‘caro conte mio, to do no such thing,
for you will ruin your wall. What! whitewash it over!—it is profanation, sacrilege,
murder, and arson.’
“He opened his eyes. ‘Ah! I did not mean to whitewash it, but to wash it over
with a pearl colour,’ he answered.
“‘Whatever you do to it you will spoil it. Pray let it alone. It is beautiful now.’
“‘Is it, indeed?’ he cried. ‘Well, I hadn’t the least idea of that. But if you say so, I
will let it alone.’
“And thus we saved a wall.”
 The preceding scrap reminds us of a passage from Alphonse Karr,
one of the most quietly-humorous of living French writers, who
relates, in one of his quaint, dreamy, desultory books, how a
neighbour of his, who lived in a poor thatched cottage on the fringe
of a wood, embowered in flowers, shaded by venerable trees,
refreshed by the balmiest of breezes, and enlivened by the songs of
countless birds, suddenly disappeared from the countryside. Karr,
who had long admired the sylvan retreat, and almost envied its
occupant, inquired his fate. He had become rich, he was told; a
legacy had enabled him to go and live in the town. He could afford to
rent two rooms with new furniture and a gaudy paper, and he looked
out upon a dirty street, along which omnibuses continually rolled.
“Poor rich man!” Karr pitying exclaims. He had whitewashed his
wall.
The Roman Ghetto furnishes the theme of one of Mr Story’s
longest and most lively chapters; Fountains and Aqueducts, Saints
and Superstitions, the Evil Eye, are the titles of three others. He
begins his second volume with a vivid and characteristic sketch of the
Markets of Rome, which are well worth the attention of foreign
visitors, especially of Englishmen, who will find their arrangements,
and much of what is there sold, to contrast strikingly with what they
are accustomed to in their own country. Carcasses of pigs and goats
adorned with scraps of gold-leaf and tinsel, blood puddings of a
brilliant crimson, poultry sold by retail—that is to say, piecemeal, so
that you may buy a wing, a leg, or even the head or gizzard of a fowl,
if so it please you. There is game of all sorts, and queer beasts and
fowls of many kinds are also there; the wild boar rough and snarling
—the slender tawny deer—porcupines (commonly eaten in Rome)—
most of our English game-birds—ortolans, beccaficoes, and a great
variety of singing-birds. Passing into the fruit and vegetable market,
one comes upon mushrooms of many colours, and some of them of
enormous size, most of which would in England be looked upon as
sudden death to the consumer, although in Italy they are found both
savoury and harmless. “Here are the grey porcini, the foliated
alberetti, and the orange-hued ovole; some of the latter of enormous
size, big enough to shelter a thousand fairies under their smooth and
painted domes. In each of these is a cleft stick, bearing a card from
the inspector of the market, granting permission to sell; for
mushrooms have proved fatal to so many cardinals, to say nothing of
popes and people, that they are naturally looked upon with
suspicion, and must all be officially examined to prevent accidents.”
Besides the fruits common in England, figs are very abundant, and of
many kinds; and when the good ones come in, in September, the
Romans of the lower classes assemble in the evenings, in the Piazza
Navona, for great feeds upon them. Five or six persons surround a
great basket and eat it empty, correcting possible evil results by a
glass of strong waters or a flask of red wine. But figs are a wholesome
fruit—much more so than one which at Rome, and in many parts of
Southern Europe, is the most popular of all—namely, the water-
melon. What millions of people, from the Danube’s banks to the
Portuguese coast, are daily refreshed the summer through by those
huge green gourds, hard and unpromising in outward aspect, but
revealing, at stroke of knife, rich store of rosy pulp, dotted with sable
seeds! Pesth is a great place for them; and daily, when morning
breaks, so long as they are in season, they are to be seen piled, all
along the river-side, in heaps like those of shot and shell in an
arsenal, only much broader and higher. All through the hot months,
in Hungary’s pleasant and interesting capital, few persons think of
dining without associating with the more heating viands a moiety or
enormous segment of one of those great cold fruits—a strange
digestive, as we Northerners should consider it, but found to answer
well in sultry climes. At Rome they are equally appreciated, and are
set above the choicest grapes. People make parties to go out of the
city and eat them; and this was especially the case some years ago,
when the authorities forbade their entrance on account of the
cholera, but were unable to prevent their extramural consumption.
In ordinary times you find heaps of them in the streets, especially in
the Piazza Navona, that great mart of fruit and frippery, vegetables,
old books, brilliant handkerchiefs, and other finery for the market-
women—old iron, old bottles, and rubbish of all kinds—amongst
which miscellany the patient investigator may sometimes discover
valuable copies of the classic authors and precious antique intagli, to
be purchased for a mere song. Here, as the story goes, a poor priest
once bought, for a few baiocchi, a large cut-glass bead which took his
fancy, and which a friend, more knowing than himself, afterwards
discovered to be a diamond of great value, now belonging, we are
told, to the Emperor of Russia. The priest disappeared, which leaves
any ingenious and inventive writer full liberty to build a romantic
tale upon the incident. The natural finale of the affair, Mr Story
opines, would have been for the priest to have married the Emperor’s
daughter, but his being in orders was an impediment; and so we are
justified in presuming that some less agreeable means was found of
easing him of his jewel, which, when he first possessed it, he took to
be a drop from a chandelier, but to which he of course clung with
desperate tenacity when enlightened as to the quality of the gem.
Rome ought to be a good preserve for fiction-writers, there are so
many family histories, traditions, and anecdotes current there, which
would serve the novelist’s turn. Edmund About availed himself of
one such in his tale of ‘Tolla;’ and another over-true tale was
interwoven, not very long since, in a pleasant novelet of Roman life
in the pages of this Magazine. Mr Story’s volumes abound in
suggestive passages of the kind. If Rome be an admirable residence
for an artist (and for some of the reasons why it is so, see the ‘Roba,’
i. p. 66, 67), it ought also to be an excellent one for a writer, were it
not that it is found by many unfavourable to mental exertion. This is
said to be particularly exemplified in the case of diplomatists, many
of whom, after a certain time passed in the Papal capital, are apt to
conceive an intense dislike to despatch-writing, and to keep their
Governments extremely uninformed concerning the state of the Holy
City and the prospects of Pontifical politics. We remember to have
been told, when in Rome, the names of more than one foreign
minister who had been recalled, it was asserted, for no other reason
but that nothing could induce him to write despatches. Rome is
certainly one of the places where there is most temptation, at least
for one half of the year, to neglect business for pleasure; but there is
possibly also something in the climate which disinclines many people
to headwork. It is much the fashion to abuse the Roman climate; and
this has been done, especially of late, by persons desirous to show
that Rome is an undesirable, because a highly insalubrious, capital
for united Italy. It is to be feared the grapes are sour, and that the
yellow flag now hoisted would be struck at the same time with the
French tricolour. Our own experience and observations induce us
very much to concur with those passages of Mr Story’s book which
relate to this question. “Rome has, with strangers, the reputation of
being unhealthy; but this opinion I cannot think well founded—to the
extent, at least, of the common belief.” Many maladies, virulent and
dangerous elsewhere, are very light in Rome; and for lung
complaints it is well known that people repair thither. The “Roman
fever,” as it is commonly called (intermittent and perniciosa), is
seldom suffered from by the better classes of Romans; and Mr Story
(who speaks with authority after his many years’ residence in Rome)
believes that, with a little prudence, it may easily be avoided. The
peasants of the Campagna are, it is well known, those who chiefly
suffer from it, and why? “Their food is poor, their habits careless,
their labour exhausting and performed in the sun, and they sleep
often on the bare ground or a little straw. And yet, despite the life
they lead and their various exposures, they are, for the most part, a
very strong and sturdy class.” Mr Story gives it as a fact that the
French soldiers who besieged Rome in ‘48, during the summer
months, suffered very little from fever, although sleeping out on the
Campagna; but they were better clothed and fed, and altogether
more careful of themselves, than the native peasants. Generally
speaking, the foreigners who visit Rome are less attentive than the
Romans to certain common rules for the preservation of health. They
eat and drink too much, and of the wrong things. They get hot, and
then plunge into cold churches or galleries; whereas an Italian flies
from a chill or current of air as from infection. Mr Story gives a few
simple rules, by following which he declares you may live twenty
years in Rome without a fever. He cautions Englishmen against
copious dinners, sherry and brandy, and his own countrymen against
the morning-dinner which they call a breakfast; and supplies other
useful hints and practical remarks. The subject is one which interests
many, and such are referred to the ‘Roba,’ i. p. 156–161, and to the
chapter on the Campagna, in which high authorities and ingenious
arguments are brought to prove that in old times it was not
insalubrious, and that in our own it need not be so. Population and
cultivation are perhaps all that are needed to render tracts healthy
that now are pestilential, but which assuredly were not so in the time
of the ancient Romans, since many of them, we know, were their
favourite sites for patrician villas. Much might be done by an
intelligent and active government, and especially by a good sanitary
commission. There was one clever gentleman who wrote that Rome
was ill fitted to be the capital of Italy on account of its deficiency in
buildings suitable for government offices! Where good reasons are
not to be found silly ones may be resorted to, but they of course only
weaken the cause they are intended to prop. And if it were to be
urged that all the worst plagues flesh is heir to, combine to render
Rome for the present impossible as capital of Italy, the most we
could admit, by way of compromise, and borrowing a well-known
answer, would be, “non tutti, ma Buona parte.”
 CAXTONIANA:
A SERIES OF ESSAYS ON LIFE,
LITERATURE, AND MANNERS.
By the Author of ‘The Caxton Family.’
PART XV.

NO. XX.—ON SELF-CONTROL.

“He who desires to influence others must learn to command
himself,” is an old aphorism, on which, perhaps, something new may
be said. In the ordinary ethics of the nursery, self-control means little
more than a check upon temper. A wise restraint, no doubt; but as
useful to the dissimulator as to the honest man. I do not necessarily
conquer my anger because I do not show that I am angry. Anger
vented often hurries towards forgiveness; anger concealed often
hardens into revenge.
A hasty temper is not the only horse that runs away with the
charioteer on the Road of Life. Nor is it the most dangerous, for it
seldom runs away far. It gives a jerk and a shake; but it does not take
the bit between its teeth, and gallop blindly on, mile after mile, in
one obstinate direction towards a precipice. A hasty temper is an
infirmity disagreeable to others, undignified in ourselves—a fault so
well known to every man who has it, that he will at once acknowledge
it to be a fault which he ought to correct. He requires, therefore, no
moralising essayist to prove to him his failing, or teach him his duty.
But still a hasty temper is a frank offender, and has seldom that
injurious effect either on the welfare of others, or on our own
natures, mental and moral, which results from the steady purpose of
one of those vices which are never seen in a passion.
 In social intercourse, if his character be generous and his heart
sound, a man does not often lose a true friend from a quick word.
And even in the practical business of life, wherein an imperturbable
temper is certainly a priceless advantage, a man of honesty and
talent may still make his way without it. Nay, he may inspire a
greater trust in his probity and candour, from the heat he displays
against trickiness and falsehood. Indeed there have been
consummate masters in the wisdom of business who had as little
command of temper as if Seneca and Epictetus had never proved the
command of temper to be the first business of wisdom. Richelieu
strode towards his public objects with a footstep unswervingly firm,
though his servants found it the easiest thing in the world to put him
into a passion. Sometimes they did so on purpose, pleased to be
scolded unjustly, because sure of some handsome amends. And in
treating of self-control, I am contented to take that same Richelieu,
the Cardinal, as an illustration of the various and expansive meaning
which I give to the phrase. Richelieu did not command his temper in
the sphere of his private household: he commanded it to perfection
in his administration of a kingdom. He was cruel, but from policy,
not from rage. Among all the victims of that policy, there was not one
whose doom could be ascribed to his personal resentments. The life
of no subject, and the success of no scheme, depended on the chance
whether the irritable minister was in good or bad humour. If he
permitted his temper free vent in his household, it was because there
he was only a private individual. There, he could indulge in the
luxury of ire without disturbing the mechanism of the state. There,
generous as a noble and placable as a priest, he could own himself in
the wrong, and beg his servants’ forgiveness, without lowering the
dignity of the minister, who, when he passed his threshold, could ask
no pardon from others, and acknowledge no fault in himself. It was
there where his emotions were most held in restraint,—there where,
before the world’s audience, his mind swept by concealed in the folds
of its craft, as, in Victor Hugo’s great drama, L’Homme Rouge passes
across the stage, curtained round in his litter, a veiled symbol of
obscure, inexorable, majestic fate,—it was there where the dread
human being seemed to have so mastered his thoughts and his
feelings, that they served but as pulleys and wheels to the bloodless
machine of his will,—it was there that self-control was in truth the
most feeble. And this apparent paradox brings me at once to the
purpose for which my essay is written.
What is Self? What is that many-sided Unity which is centred in
the single Ego of a man’s being? I do not put the question
metaphysically. Heaven forbid! The problem it involves provokes the
conjectures of all schools, precisely because it has received no
solution from any. The reader is welcome to whatever theory he may
prefer to select from metaphysical definitions, provided that he will
acknowledge in the word Self the representation of an integral
individual human being—the organisation of a certain fabric of flesh
and blood, biassed, perhaps, originally by the attributes and
peculiarities of the fabric itself—by hereditary predispositions, by
nervous idiosyncrasies, by cerebral developments, by slow or quick
action of the pulse, by all in which mind takes a shape from the
mould of the body;—but still a Self which, in every sane constitution,
can be changed or modified from the original bias, by circumstance,
by culture, by reflection, by will, by conscience, through means of the
unseen inhabitant of the fabric. Not a man has ever achieved a
something good or great, but will own that, before he achieved it, his
mind succeeded in conquering or changing some predisposition of
body.
True self-control, therefore, is the control of that entire and
complex unity, the individual Self. It necessitates an accurate
perception of all that is suggested by the original bias, and a power to
adapt and to regulate, or to oppose and divert, every course to which
that bias inclines the thought and impels the action.
For Self, left to itself, only crystallises atoms homogeneous to its
original monad. A nature constitutionally proud and pitiless,
intuitively seeks, in all the culture it derives from intellectual labour,
to find reasons to continue proud and pitiless—to extract from the
lessons of knowledge arguments by which to justify its impulse, and
rules by which the impulse can be drilled into method and refined
into policy.
Among the marvels of psychology, certainly not the least
astounding is that facility with which the conscience, being really
sincere in its desire of right, accommodates itself to the impulse
which urges it to go wrong. It is thus that fanatics, whether in
religion or in politics, hug as the virtue of saints and heroes the
barbarity of the bigot, the baseness of the assassin. No one can
suppose that Calvin did not deem that the angels smiled approbation
when he burned Servetus. No one can suppose that when
Torquemada devised the Inquisition, he did not conscientiously
believe that the greatest happiness of the greatest number could be
best secured by selecting a few for a roast. Torquemada could have
no personal interest in roasting a heretic; Torquemada did not eat
him when roasted; Torquemada was not a cannibal.
Again: no one can suppose that when the German student, Sand,
after long forethought, and with cool determination, murdered a
writer whose lucubrations shocked his political opinions, he did not
walk to the scaffold with a conscience as calm as that of the mildest
young lady who ever slaughtered a wasp from her fear of its sting.
So when Armand Richelieu marched inflexibly to his public ends,
the spy on his left side, the executioner on his right, Bayard could not
have felt himself more free from stain and reproach. His conscience
would have found in his intellect not an accusing monitor but a
flattering parasite. It would have whispered in his ear—“Great Man—
Hero, nay, rather Demigod[5]—to destroy is thy duty, because to
reconstruct is thy mission. The evils which harass the land—for
which Heaven, that gave thee so dauntless a heart and so scheming a
brain, has made thee responsible—result from the turbulent
ambition of nobles who menace the throne thou art deputed to
guard, and the licence of pestilent schisms at war with the Church of
which thou art the grace and the bulwark. Pure and indefatigable
patriot, undeterred by the faults of the sovereign who hates thee, by
the sins of the people who would dip their hands in thy blood, thou
toilest on in thy grand work serenely, compelling the elements vainly
conflicting against thee into the unity of thine own firm design—
unity secular, unity spiritual—one throne safe from rebels, one
church free from schisms; in the peace of that unity, the land of thy
birth will collect and mature and concentrate its forces, now wasted
and waning, till it rise to the rank of the one state of Europe—the
brain and the heart of the civilised world! No mythical Hercules
thou! Complete thy magnificent labours. Purge the land of the Lion
and Hydra—of the throne-shaking Baron—the church-splitting
Huguenot!”
 5. An author dedicated a work to Richelieu. In the dedication, referring to the
‘Siege of Rochelle,’ he complimented the Cardinal with the word Hero. When the
dedication was submitted to Richelieu for approval, he scratched out “Hèros,” and
substituted “Demi-Dieu!”
Armand Richelieu, by nature not vindictive nor mean, thus
motions without remorse to the headsman, listens without shame to
the spy, and, when asked on his deathbed if he forgave his enemies,
replies, conscientiously ignorant of his many offences against the
brotherhood between man and man, “I owe no forgiveness to
enemies; I never had any except those of the State.”
For human governments, the best statesman is he who carries a
keen perception of the common interests of humanity into all his
projects, howsoever intellectually subtle. But that policy is not for the
interests of humanity which cannot be achieved without the spy and
the headsman. And those projects cannot serve humanity which
sanction persecution as the instrument of truth, and subject the fate
of a community to the accident of a benevolent despot.
In Richelieu there was no genuine self-control, because he had
made his whole self the puppet of certain fixed and tyrannical ideas.
Now, in this the humblest and obscurest individual amongst us is too
often but a Richelieu in miniature. Every man has in his own
temperament peculiar propellers to the movement of his thoughts
and the choice of his actions. Every man has his own favourite ideas
rising out of his constitutional bias. At the onset of life this bias is
clearly revealed to each. No youth ever leaves college but what he is
perfectly aware of the leading motive-properties of his own mind. He
knows whether he is disposed by temperament to be timid or rash,
proud or meek, covetous of approbation or indifferent to opinion,
thrifty or extravagant, stern in his justice or weak in his indulgence.
It is while his step is yet on the threshold of life that man can best
commence the grand task of self-control; for then he best adjusts
that equilibrium of character by which he is saved from the
despotism of one ruling passion or the monomania of one cherished
train of ideas. Later in life our introvision is sure to be obscured—the
intellect has familiarised itself to its own errors, the conscience is
deafened to its own first alarms; and the more we cultivate the
intellect in its favourite tracks, the more we question the conscience
in its own prejudiced creed, so much the more will the intellect find
skilful excuses to justify its errors, so much the more will the
conscience devise ingenious replies to every doubt we submit to the
casuistry of which we have made it the adept.
Nor is it our favourite vices alone that lead us into danger—noble
natures are as liable to be led astray by their favourite virtues; for it
is the proverbial tendency of a virtue to fuse itself insensibly into its
neighbouring vice; and, on the other hand, in noble natures, a
constitutional vice is often drilled into a virtue.
But few men can attain that complete subjugation of self to the
harmony of moral law, which was the aim of the Stoics. A mind so
admirably balanced that each attribute of character has its just
weight and no more, is rather a type of ideal perfection, than an
example placed before our eyes in the actual commerce of life. I must
narrow the scope of my homily, and suggest to the practical a few
practical hints for the ready control of their faculties.
It seems to me that a man will best gain command over those
intellectual faculties which he knows are his strongest, by cultivating
the faculties that somewhat tend to counterbalance them. He in
whom imagination is opulent and fervid will regulate and discipline
its exercise by forcing himself to occupations or studies that require
plain common sense. He who feels that the bias of his judgment or
the tendency of his avocations is over-much towards the positive and
anti-poetic forms of life, will best guard against the narrowness of
scope and feebleness of grasp which characterise the intellect that
seeks common sense only in commonplace, by warming his faculties
in the glow of imaginative genius; he should not forget that where
heat enters it expands. And, indeed, the rule I thus lay down,
eminent men have discovered for themselves. Men of really great
imagination will be found to have generally cultivated some branch
of knowledge that requires critical or severe reasoning. Men of really
great capacities for practical business will generally be found to
indulge in a predilection for works of fancy. The favourite reading of
poets or fictionists of high order will seldom be poetry or fiction.
Poetry or fiction is to them a study, not a relaxation. Their favourite
reading will be generally in works called abstruse or dry—antiquities,
metaphysics, subtle problems of criticism, or delicate niceties of
scholarship. On the other hand, the favourite reading of celebrated
lawyers is generally novels. Thus in every mind of large powers there
is an unconscious struggle perpetually going on to preserve its
equilibrium. The eye soon loses its justness of vision if always
directed towards one object at the same distance—the soil soon
exhausts its produce if you draw from it but one crop.
But it is not enough to secure counteraction for the mind in all
which directs its prevailing faculties towards partial and special
results; it is necessary also to acquire the power to keep differing
faculties and acquirements apart and distinct on all occasions in
which it would be improper to blend them. When the poet enters on
the stage of real life as a practical man of business, he must be able to
leave his poetry behind him; when the practical man of business
enters into the domain of poetry, he must not remind us that he is an
authority on the Stock Exchange. In a word, he who has real self-
control has all his powers at his command, now to unite and now to
separate them.
In public life this is especially requisite. A statesman is seldom
profound unless he be somewhat of a scholar; an orator is seldom
eloquent unless he have familiarised himself with the world of the
poets. But he will never be a statesman of commanding influence,
and never an orator of lasting renown, if, in action or advice on the
practical affairs of nations, he be more scholar or poet than orator or
statesman. Pitt and Fox are memorable instances of the
discriminating self-abnegation with which minds of masculine power
can abstain from the display of riches unsuited to place and occasion.
In the Mr Fox of St Stephen’s, the nervous reasoner from premises
the broadest and most popular, there is no trace of the Mr Fox of St
Anne’s, the refining verbal critic, with an almost feminine delight in
the filigree and trinkets of literature. At rural leisure, under his
apple-blossoms, his predilection in scholarship is for its daintiest
subtleties; his happiest remarks are on writers very little read. But
place the great Tribune on the floor of the House of Commons, and
not a vestige of the fine verbal critic is visible. His classical allusions
are then taken from passages the most popularly known. And,
indeed, it was a saying of Fox’s, “That no young member should
hazard in Parliament a Latin quotation not found in the Eton
Grammar.”
Pitt was yet more sparing than Fox in the exhibition of his
scholarship, which, if less various than his rival’s, was probably quite
as deep. And one of the friends who knew him best said, that Pitt
rigidly subdued his native faculty of wit, not because he did not
appreciate and admire its sparkles in orators unrestrained by the
responsibilities of office, but because he considered that a man in the
position of First Minister impaired influence and authority by the
cheers that transferred his reputation from his rank of Minister to
his renown as Wit. He was right. Grave situations are not only
dignified but strengthened by that gravity of demeanour which is not
the hypocrisy of the would-be wise, but the genuine token of the
earnest sense of responsibility.
Self-control thus necessitates, first, Self-Knowledge—the
consciousness and the calculation of our own resources and our own
defects. Every man has his strong point—every man has his weak
ones. To know both the strong point and the weak ones is the first
object of the man who means to extract from himself the highest
degree of usefulness with the least alloy of mischief. His next task is
yet more to strengthen his strong points by counterbalancing them
with weights thrown into the scale of the weak ones; for force is
increased by resistance. Remedy your deficiencies, and your merits
will take care of themselves. Every man has in him good and evil. His
good is his valiant army, his evil is his corrupt commissariat; reform
the commissariat, and the army will do its duty.
The third point in Self-control is Generalship—is Method—is that
calm science in the midst of movement and passion which decides
where to advance, where to retreat—what regiments shall lead the
charge, what regiments shall be held back in reserve. This is the last
and the grandest secret: the other two all of us may master.
The man who, but with a mind somewhat above the average
(raised above the average whether by constitutional talent or
laborious acquirement), has his own intellect, with all its stores,
under his absolute control,—that man can pass from one state of idea
to another—from action to letters, from letters to action—without
taking from one the establishment that would burden the other. It is
comparatively a poor proprietor who cannot move from town to
country but what he must carry with him all his servants and half his
furniture. He who keeps the treasures he has inherited or saved in
such compartments that he may know where to look for each at the
moment it is wanted, will rarely find himself misplaced in any
change of situation. It is not that his genius is versatile, but that it
has the opulent attributes which are essential to successful intellect
of every kind. The attributes themselves may vary in property and in
degree, but the power of the Self—of the unity which controls all at
its disposal—should be in the facility with which it can separate or
combine all its attributes at its will.
It is thus, in the natural world, that an ordinary chemist may
accomplish marvels beyond the art of magicians of old. Each man of
good understanding, who would be as a chemist to the world within
himself, will be startled to discover what new agencies spring into
action merely by separating the elements dormant when joined, or
combining those that were wasted in air when apart. In one
completed Man there are the forces of many men. Self-control is self-
completion.
 NO. XXI.—THE MODERN MISANTHROPE.
“All the passions,” saith an old writer, “are such near neighbours,
that if one of them is on fire the others should send for the buckets.”
Thus love and hate being both passions, the one is never safe from
the spark that sets the other ablaze. But contempt is passionless; it
does not catch, it quenches fire. The misanthrope who professes to
hate mankind has generally passed to that hate from too extravagant
a love. And love for mankind is still, though unconsciously to
himself, feeding hate by its own unextinguished embers. “The more a
man loves his mistress,” says Rochefoucauld, “the nearer he is to
hate her.” Possibly so, if he is jealous; but in return, the more he
declares he hates her, the nearer he is to loving her again. Vehement
affections do not move in parallels but in circles. As applied to them
the proverb is true, “Les extrêmes se touchent.” A man of ardent
temperament who is shocked into misanthropy by instances of
ingratitude and perfidy, is liable any day to be carried back into
philanthropy, should unlooked-for instances of gratitude and truth
start up and take him by surprise. But if an egotist, who, inheriting
but a small pittance of human affection, concentres it rigidly on
himself, should deliberately school his reason into calm contempt for
his species, he will retain that contempt to the last. He looks on the
world of man, with its virtues and vices, much as you, O my reader,
look on an ant-hill! What to you are the virtues or vices of ants? It is
this kind of masked misanthropy which we encounter in our day—
the misanthropy without a vizard belongs to a ruder age.
The misanthrope of Shakespeare and Molière is a passionate
savage; the misanthrope who has just kissed his hand to you is a
polished gentleman. No disgust of humanity will ever make him fly
the world. From his club-window in St James’s his smile falls on all
passers-by with equal suavity and equal scorn. It may be said by
verbal critics that I employ the word misanthrope incorrectly—that,
according to strict interpretation, a misanthrope means not a
despiser but a hater of men, and that this elegant gentleman is not,
by my own showing, warmblooded enough for hate. True, but
contempt so serene and immovable is the philosophy of hate—the
intellectual consummation of misanthropy. My hero would have
listened with approving nod to all that Timon or Alceste could have
thundered forth in detestation of his kind, and blandly rejoined,
“Your truisms, mon cher, are as evident as that two and two make
four. But you can calculate on the principle that two and two make
four without shouting forth, as if you proclaimed a notable discovery,
what every one you meet knows as well as yourself. Men are
scoundrels—two and two make four—reckon accordingly, and don’t
lose your temper in keeping your accounts.” My misanthrope à la
mode never rails at vice; he takes it for granted as the elementary
principle in the commerce of life. As for virtue, he regards it as a
professor of science regards witchcraft. No doubt there are many
plausible stories, very creditably attested, that vouch for its
existence, but the thing is not in nature. Easier to believe in a
cunning imposture than an impossible fact. It is the depth and
completeness of his contempt for the world that makes him take the
world so pleasantly. He is deemed the man of the world par
excellence, and the World caresses and admires its Man.
The finest gentleman of my young day, who never said to you an
unkind thing nor of you a kind one—whose slightest smile was a
seductive fascination—whose loudest tone was a flute-like melody—
had the sweetest way possible of insinuating his scorn of the human
race. The urbanity of his manners made him a pleasant acquaintance
—the extent of his reading an accomplished companion. No one was
more versed in those classes of literature in which Mephistopheles
might have sought polite authorities in favour of his demoniacal
views of philosophy. He was at home in the correspondence between
cardinals and debauchees in the time of Leo X. He might have taken
high honours in an examination on the memoirs illustrating the life
of French salons in the ancien régime. He knew the age of Louis
Quinze so well that to hear him you might suppose he was just fresh
from a petit souper in the Parc aux Cerfs.
Too universally agreeable not to amuse those present at the
expense of those absent, still, even in sarcasm, he never seemed to be
ill-natured. As one of his associates had a louder reputation for wit
than his own, so it was his modest habit to father upon that
professed diseur de bons mots any more pointed epigram that
occurred spontaneously to himself. “I wonder,” said a dandy of
another dandy who was no Adonis, “why on earth —— has suddenly
taken to cultivate those monstrous red whiskers.” “Ah,” quoth my
pleasant fine gentleman, “I think for my part they become his style of
face very much; A—— says ‘that they plant out his ugliness.’” For the
rest, in all graver matters, if the man he last dined with committed
some act which all honest men blamed, my misanthrope evinced his
gentle surprise, not at the act, but the blame—“What did you
expect?” he would say, with an adorable indulgence, “he was a man—
like yourselves!”
Sprung from one of the noblest lineages in Christendom—
possessed of a fortune which he would smilingly say “was not large
enough to allow him to give a shilling to any one else,” but which,
prudently spent on himself, amply sufficed for all the elegant wants
of a man so emphatically single—this darling of fashion had every
motive conceivable to an ordinary understanding not to be himself
that utter rogue which he assumed every other fellow-creature to be.
Nevertheless, he was too nobly consistent to his creed to suffer his
example to be at variance with his doctrine; and here he had an
indisputable advantage over Timon and Alceste, who had no right,
when calling all men rogues, to belie their assertion by declining to
be rogues themselves. His favourite amusement was whist, and in
that game his skill was so consummate that he had only to play fairly
in order to add to his income a sum which, already spending on
himself all that he himself required, he would not have known what
to do with. But, as he held all men to be cheats, he cheated on
principle. It was due to the honour of his philosophy to show his
utter disdain of the honour which impostors preached, but which
only dupes had the folly to practise. If others did not mark the aces
and shuffle up the kings as he did, it was either because they were too
stupid to learn how, or too cowardly to risk the chance of exposure.
He was not as stupid, he was not as cowardly, as the generality of
men. It became him to show his knowledge of their stupidity and his
disdain of their cowardice. Bref—he cheated!—long with impunity:
but, as Charron says, L’homme se pique—man cogs the dice for his
own ruin. At last he was suspected, he was watched, he was detected.
But the first thought of his fascinated victims was not to denounce,
but to warn him—kindly letters conveying delicate hints were
confidentially sent to him: he was not asked to disgorge, not
exhorted to repent; let bygones be bygones, only for the future,
would he, in playing with his intimate associates, good-naturedly
refrain from marking the aces and shuffling up the kings?
I can well imagine the lofty smile with which the scorner of men
must have read such frivolous recommendations to depart from the
philosophical system adorned in vain by his genius if not enforced by
his example. He who despised the opinions of sages and saints—he to
be frightened into respecting the opinions of idlers at a club!—send
to him an admonition from the world of honour, to respect the
superstitions of card-players! as well send to Mr Faraday an
admonition from the world of spirits to respect the superstitions of
table-rappers! To either philosopher there would be the same reply
—“I go by the laws of nature.” In short, strong in the conscience of
his opinion, this consistent reasoner sublimely persevered in
justifying his theories of misanthropy by his own resolute practice of
knavery, inexcusable and unredeemed.
“What Timon thought, this god-like Cato was!”

But man, whatever his inferiority to the angels, is still not

altogether a sheep. And even a sheep only submits to be sheared
once a year; to be sheared every day would irritate the mildest of
lambs. Some of the fellow-mortals whom my hero smiled on and
plundered, took heart, and openly accused him of marking the aces
and shuffling up the kings. At first his native genius suggested to him
the wisdom of maintaining, in smiling silence, the contempt of
opinion he had hitherto so superbly evinced. Unhappily for himself,
he was induced by those who, persuaded that a man of so high a
birth could never have stooped to so low a peccadillo, flattered him
with the assurance of an easy triumph over his aspersers—unhappily,
I say, he was induced into a departure from that system of action
which he had hitherto maintained with so supreme a success. He
condescended, for the first time in his life, to take other men into
respect—to regard what might be thought of him by a world he
despised. He brought an action for libel against his accusers. His
counsel, doubtless by instruction, sought to redeem that solitary
inconsistency in his client, by insinuating that my lord’s chosen
associates were themselves the cheats, malignant conspirators
against the affable hawk of quality in whom they had expected to find
a facile pigeon.
 The cuttle-fish blackens the water to escape from his enemies, but
he does not always escape; nay, in blackening the water he betrays
himself to the watchful spectators. My hero failed in his action, and
quitted the court leaving behind him the bubble reputation. If I am
rightly informed, Adversity, that touchstone of lofty minds, found
this grand philosopher as serene as if he had spent his life in
studying Epictetus. He wrapt himself, if not in virtue, at least in his
scorn of it,—
“Et udo
Spernit humi defugiente penno.”

He retired to the classic Tusculum of his villa in St John’s Wood.

There, cheered by the faithful adherence of some elegant
companions, who, if they did not believe him innocent, found him
unalterably agreeable, he sipped his claret and moralised on his
creed. Doubtless he believed that “the talk would soon subside,” “the
thing blow over.” The world would miss him too much not to rally
again round the sage who so justly despised it. Perhaps his belief
might have been realised, but,
“Vita summa brevis spem nos vetat inchoare longam”—

Death, the only player that no man can cheat, cut into his table,
and trumped the last card of his long suit.
In the more brilliant period of this amiable man-scorner’s social
career, once, and once only, he is said to have given way to anger.
One of his associates (I say designedly associates, not friends, out of
respect for his memory, since friendship is a virtue, and he therefore
denied its existence)—one of his associates, warmed perhaps into
literature by his own polite acquaintance with all that is laide in
belles lettres, wrote a comedy. The comedy was acted. My hero
honoured the performance by appearing in the author’s box. Leaning
forward so as to be seen of all men, he joined his hands in well-bred
applause of every abortive joke and grammatical solecism, till, in a
critical part of the play, there occurred a popular claptrap—a
something said in praise of virtue and condemnation of vice. The
gallery of course responded to the claptrap, expressing noisy
satisfaction at the only sentiment familiar to their comprehension
which they had hitherto heard. But my archetype of modern
misanthropy paused aghast, suspended
“The soft collision of applauding gloves,”

and, looking at his associate as reproachfully as Cæsar might have

looked at Brutus when he sighed forth “Et tu, Brute!” let fall these
withering words, “Why, Billy, this is betraying the Good Old Cause.”
So saying, he left the box, resentful. Now, this man I call the genuine,
positive, realistic Misanthrope, compared to whom Timon and
Alceste are poetical make-believes!
 SPEDDING’S LIFE OF BACON.[6]
6. ‘The Letters and the Life of Francis Bacon.’ By James Spedding. Vols. I. & II.
Lord Macaulay’s ‘Essay on Francis Bacon.’
Mr Spedding, in the modest form of a commentary on the letters
and occasional writings of Lord Bacon, is now giving us a biography
of that celebrated man, which bids fair, for a long time to come, to be
our highest authority on the subject. To place all the facts before us
on which our judgment of the character of Lord Bacon should be
formed, is his great object; he deals in few assertions of his own; he is
disposed to let facts speak for themselves; he guides our opinion by a
full narrative of the events, and makes few attempts to influence us
by argument or eloquence. A more satisfactory or trustworthy book
has rarely come before us.
We will not say that Mr Spedding’s narrative is never coloured by
an imagination which has received its unconscious prompting from
his admiration of Bacon: one rather amusing instance of this
colouring of the imagination we think we have detected, and shall
have occasion to notice; but no admiring biographer of a great man
has more studiously refrained from thrusting forward his own
opinions or conceptions where the reader is merely desirous of
obtaining a clear insight into the facts themselves. Mr Spedding has
not yet completed his task, but he has given us in these two volumes
more materials of interest than in the space of a single paper we shall
have room to touch upon, and the main topic which occupies them is
fully discussed and finally dismissed.
That topic is the relation between Bacon and Essex. Of the
splendid Essay of Lord Macaulay’s, which is still ringing in the ears
of most English readers, no part was written with more force, or was
more damaging to the character of Bacon, than that which treated of
his conduct to the Earl of Essex. Many who could have forgiven the
peccant Chancellor for being too ready to accept whatever was
offered to him in the shape of present or gratuity, could not pardon
the cold-blooded and faithless friend. Now it is precisely on this
subject that Mr Spedding presents us with materials for forming a
very different judgment from that which the eloquent pages of
Macaulay had betrayed us into. Up to the period when Essex
disappears from the scene, these two volumes give us their clear
guidance. Of that guidance we very gladly avail ourselves.
We would premise that it is not our purpose, or endeavour, to
defend Bacon at all points—to robe our Chancellor in spotless
ermine; neither do we think that the result of renewed investigation
is a clear verdict of “Not Guilty” on all the charges that have been
brought against him. There is much in Macaulay’s estimate both of
the character and the philosophy of Bacon with which we cordially
agree. It happens frequently with great historic names that there is
an oscillation of public opinion; the too harsh verdict of one writer,
or one age, is followed by a verdict as much too lenient. Such
oscillation seems to have lately taken place with regard to Bacon, and
the disposition is at present to find nothing blameworthy in him.
This disposition we do not share. We think that no good is done, but
rather harm, when enthusiasm for the brilliant achievements of any
man, whether in a career of war, or statesmanship, or letters, induces
us to shut our eyes to his moral defects. For in these cases we do not,
and cannot, exactly shut our eyes: we do something worse; we try to
see that vices are not vices. We lower our standard, that we may pass
no unfavourable judgment. It is an ill lesson that teaches us to
forgive the overbearing despotism of a great soldier or great
minister, or the rascality of a great wit; to see no injustice in a
Napoleon, and no villany in a Sheridan. We believe that the censure
of Lord Macaulay is too severe, but it is censure and not praise which
the character of Bacon provokes. We all know that the fervid
eloquence, or rather the ardent temperament, of our more than
English Livy, led him into manifest exaggerations; but in general, we
should say that his drawing is true to nature, except that it had this
too swelling outline. His exaggerations were like those of Michael
Angelo, who drew muscles disproportionately large, but who never
drew a muscle where none existed. A sterling good sense presided
over the verdicts of Macaulay—over the yes or no; but the verdict
once determined, the impassioned orator ran the risk of falsifying it
by the ruthless, unmitigated energy with which it was delivered.
 We should not say of Bacon either that he was the “greatest” or the
“meanest” of mankind. But as certainly as he was great in his
intellectual attributes, so certainly was he not great in his moral
character. Here he lacked elevation. He could tolerate artifice, and
dissimulation, and gross flattery. If the crime of Essex justified him,
as we are inclined to think it did, in breaking entirely with that
nobleman, and treating him as an enemy to the State, what are we to
say of the strain of advice which he habitually gives to Essex while
the two are yet in perfect amity? A mere personal ambition, to be
obtained by the petty arts of the courtier, is all that he prompts his
friend to aspire after. Win the Queen—honestly, if possible; but, at all
events, win the Queen! This is the burden of his counsel. Bacon was
great in his intellectual speculations; he was mean in the conduct of
life. The antithesis still remains to us in a modified form. All his life
is a continual suing for place; and what he obtained by flattery and
subservience, he lost by some poor cupidity.
Bacon was a philosopher from his youth, but from his youth to his
old age he was also a lover of social distinctions, and of a sumptuous
mode of life. If he had the desire to take all human knowledge for his
province, and to extend his name and his good influence into future
ages, if he desired to be a reformer even of philosophy itself, he had
also other desires of a much more commonplace description; not evil
in themselves—good perhaps in themselves—but not subordinated to
the high morality which might have been expected from one so wise.
But if in his rise to power he showed too much servility—if, when in
the seat of power, he showed too much cupidity,—surely no one ever
fell from greatness, no one was ever struck down from the seat of
power, for so slight a measure of criminality. No historic personage
can be mentioned amongst us, on whom so severe a punishment, so
deep a disgrace, was inflicted for a fault so little heinous.
The first great error which Bacon committed, the consequence of
which pursued him all his life, was the running into debt. It was a
life-long fault. It was his fault, not his misfortune. He received less,
we know, from his father than he might reasonably have expected,
less than his brothers had received, but no biographer has ventured
to call him poor—so poor that he could not have held his ground as a
student of the law without incurring debt. Whether it was mere
carelessness and imprudence, or a wilful spending “according to his
hopes, not his possessions,” we find him very early in debt; and as
years advance we find the debts, of course, more and more onerous.
No one knew better than Bacon that he who owes has to borrow, and
that he who borrows will have, in some form, to beg, to sue—will be
tempted to sordid actions—will lose his independence, his upright
attitude amongst men. There is no greater slavery than debt. It bred
in Bacon that “itching palm,” and that perpetual suing, which
disgrace his career.
He begins to sue from his very first entry into life. He puts his trust
in the Lord Treasurer. And what is remarkable, the very nature of the
first suit he makes is unknown. It was some office, not of a legal
character, as we should conjecture. Writing to Walsingham about it,
he says that the delay in answering it “hinders me from taking a
course of practice which, by the leave of God, if her Majesty like not
of my suit, I must and will follow: not for any necessity of estate, but
for my credit sake, which I know by living out of action will wear.” At
this date, 25th August 1585, he does not plead absolute inability to
live on his private fortune. Subsequently, when his debts have
increased, he writes upon this subject in a very different strain. He is
embarrassed by usurers; he is arrested; debt comes upon him, as he
says, like an armed man.
Of the earliest years of Bacon few memorials remain. But Mr
Spedding brings together two conspicuous facts. The first is, that
Bacon, at the age of fifteen, conceives his project of a reformation in
philosophy; and the second is, that immediately on leaving college he
accompanies Sir Amias Paulet on his embassy to France. Thus
philosophy and diplomacy, speculation and state-craft, study and the
world, take at once joint possession of Francis Bacon.
Of the first of these facts, and the most important in his life, Mr
Spedding speaks in a passage of much eloquence, glowing and
chastened withal:—

“That the thought first occurred to him during his residence at Cambridge,
therefore before he had completed his fifteenth year, we know upon the best
authority—his own statement to Dr Rawley. I believe it ought to be regarded as the
most important event of his life—the event which had a greater influence than any
other upon his character and future course. From that moment there was
awakened within his breast the appetite which cannot be satiated, and the passion
which cannot commit excess. From that moment he had a vocation which
employed and stimulated all the energies of his mind, gave a value to every vacant
interval of time, an interest and significance to every random thought and casual
accession of knowledge—an object to live for as wide as humanity, as immortal as
the human race—an idea to live in vast and lofty enough to fill the soul for ever
with religious and heroic aspirations. From that moment, though still subject to
interruptions, disappointments, errors, and regrets, he could never be without
either work or hope or consolation.”

But this young philosopher is son of Sir Nicholas Bacon, the late
Lord Chancellor; the Queen has laid her hand upon his head while
yet a boy, and called him her young Lord Keeper; he is nephew to the
Prime Minister; he dreams of courts, of place, of power. He must
unite his lofty speculations with the great affairs of State; he must
survey human knowledge from the high places of society. He enters
Gray’s Inn, is a student of the law, and his heart aches after office
and promotion.
There is one person very intimately connected with Bacon, whom
Mr Spedding has brought before us with a novel distinctness—his
mother, Lady Bacon. We are not aware that her presence will throw
much light on the character of her son, but henceforth, we are sure,
no biography of the son will be written in which this lady will not be
a conspicuous figure. She is one of those strongly-marked characters
that always please the imagination; dogmatic, perverse, full of
maternal anxiety, pious and splenetic, with marvellous shrewd sense
and a very ungovernable temper. The knowledge of her character
would enable us to answer one question. Presuming that any one
should think fit to ask why Bacon did not seek the retirement of
Gorhambury, the answer is quite ready. There would have been no
peace for him under the roof of his lady mother. Puritan and
termagant, his philosophy would have been “suspect” to her; and his
retirement would have been certainly denounced as unpardonable
sloth. She is a learned lady, mingles scraps of Latin and Greek in her
epistles, and she can write, when the occasion demands, in a very
stately English style—stately, but straightforward withal. Her son’s
epistolary style is often involved and verbose. He does not often
come so directly to the point as Lady Bacon does in the following
letter, written to Lord Burghley, in the interest of the Nonconformist
clergy, or Preachers, as they were then called. In a conference which
had lately taken place at Lambeth between them and the bishops, she
thinks they had not fair-play; she appeals, in their name, to her
Majesty and the Council:—

“They would most humbly crave, both of God in heaven, whose cause it is, and of
their Majesty, their most excellent sovereign here on earth, that they might obtain
quiet and convenient audience rather before her Majesty herself, whose heart is in
God his hand to touch and to turn, or before your Honours of the Council, whose
wisdom they greatly reverence; and if they cannot strongly prove before you out of
the word of God that reformation which they so long have called and cried for to be
according to Christ his own ordinance, then to let them be rejected with shame out
of the Church for ever.... And therefore, for such weighty conference they appeal to
her Majesty and her honourable wise Council, whom God has placed in highest
authority for the advancement of His kingdom; and refuse the bishops for judges,
who are parties partial in their own defence, because they seek more worldly
ambition than the glory of Jesus Christ.”

Mr Spedding next introduces to us the same lady under the

agitations, as he says, of maternal anxiety. Anthony Bacon, the elder
brother of Francis, has been long upon the Continent collecting
intelligence, and otherwise amusing or occupying himself. He sends
over one Lawson, a confidential servant, to Lord Burghley with some
important communication. Lawson is a Catholic. That her son
Anthony should be so long in Popish parts is a dire grievance to Lady
Bacon; that he should have in his confidence a Papist servant, is not
to be borne. She prevails upon Burghley to have this Lawson arrested
and retained in England. One snake is, at all events, caught, and shall
be held firm. Anthony writes to his friend, Francis Allen, to obtain
for him the liberation of Lawson. Allen, furnished with a letter from
Lord Burghley (who seems, for his own part, to be willing to release
the man), proceeds to Gorhambury. His intercession with Lady
Bacon he tells himself in a letter to Anthony:—

“Upon my arrival at Godombery my lady used me courteously until such time I

began to move her for Mr Lawson, and, to say the truth, for yourself;—being so
much transported with your abode there that she let not to say that you are a
traitor to God and your country: you have undone her; you seek her death; and
when you have that you seek for, you shall have but a hundred pounds more than
you have now.
 “She is resolved to procure her Majesty’s letter to force you to return; and when
that shall be, if her Majesty gave you your right or desert, she should clap you up in
prison....
“I am sorry to write it, considering his deserts and your love towards him; but
the truth will be known at the last, and better late than never: it is vain to look for
Mr Lawson’s return, for these are her ladyship’s own words—‘No, no,’ saith she, ‘I
have learned not to employ ill to good; and if there were no more men in England,
and although you should never come home, he shall never come to you.’
“It is as unpossible to persuade my lady to send him, as for myself to send you
Paul’s steeple....
“When you have received your provision, make your repair home again, lest you
be a means to shorten her days, for she told me the grief of mind received, daily by
your stay will be her end; also saith her jewels be spent for you, and that she
borrowed the last money of seven several persons.
“Thus much I must confess unto you for a conclusion, that I have never seen and
never shall see a wise lady, an honourable woman, a mother more perplexed for
her son’s absence, than I have seen that honourable dame for yours. Therefore lay
your hand on your heart, look not for Mr Lawson; here he hath, as a man may say,
heaven and earth against him and his return.”

Soon after this Anthony does return home, and Lady Bacon
addresses him a letter, in which there are some allusions to Francis,
which will be read with interest:—

“This one chiefest counsel your Christian and natural mother doth give you even
before the Lord, that above all worldly respects you carry yourself ever at your first
coming as one that doth unfeignedly profess the true religion of Christ, and hath
the love of the truth now, by long continuance, fast settled in your heart, and that
with judgment, wisdom, and discretion; and are not afraid or ashamed to testify
the same by hearing and delighting in those religious exercises of the sincerer sort,
be they French or English. In hoc noli adhibere fratrem tuum ad consilium aut
exemplum....
“I trust you, with your servants, use prayer twice in a day, having been where
reformation is. Omit it not for any. It will be your best credit to serve the Lord duly
and reverently, and you will be observed at first now. Your brother is too negligent
herein, but do you well and zealously; it will be looked for of the best-learned sort,
and that is best.”

Full of prudence, full of zeal, suspecting her sons themselves and

every one about them, anxious to manage them on all points,